[{"Id":385884,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61252580002018","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN 2.5 MG/0.5ML","NDC":"00002015204"},{"Id":385885,"FormularyType":"OHP","DrugName":"HUMULIN R INJ U-100","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104010002005","GenericName":"INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML","NDC":"00002021301"},{"Id":385886,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 5/0.5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61252580002023","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN 5 MG/0.5ML","NDC":"00002024304"},{"Id":385887,"FormularyType":"OHP","DrugName":"TRULICITY INJ 0.75/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.75","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D520","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 0.75 MG/0.5ML","NDC":"00002143301"},{"Id":385888,"FormularyType":"OHP","DrugName":"TRULICITY INJ 0.75/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.75","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D520","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 0.75 MG/0.5ML","NDC":"00002143380"},{"Id":385889,"FormularyType":"OHP","DrugName":"TRULICITY INJ 1.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D530","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 1.5 MG/0.5ML","NDC":"00002143401"},{"Id":385890,"FormularyType":"OHP","DrugName":"TRULICITY INJ 1.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D530","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 1.5 MG/0.5ML","NDC":"00002143480"},{"Id":385891,"FormularyType":"OHP","DrugName":"EMGALITY INJ 120MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"120","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203530D520","GenericName":"GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN AUTO-INJECTOR 120 MG/ML","NDC":"00002143601"},{"Id":385892,"FormularyType":"OHP","DrugName":"EMGALITY INJ 120MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"120","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203530D520","GenericName":"GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN AUTO-INJECTOR 120 MG/ML","NDC":"00002143611"},{"Id":385893,"FormularyType":"OHP","DrugName":"OMVOH INJ 200/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250405040E525","GenericName":"MIRIKIZUMAB-MRKZ SUBCUTANEOUS SOL PREFILL SYRINGE 200 MG/2ML","NDC":"00002144201"},{"Id":385894,"FormularyType":"OHP","DrugName":"OMVOH INJ 200/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250405040E525","GenericName":"MIRIKIZUMAB-MRKZ SUBCUTANEOUS SOL PREFILL SYRINGE 200 MG/2ML","NDC":"00002144211"},{"Id":385895,"FormularyType":"OHP","DrugName":"TALTZ INJ 80MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"80","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400D520","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML","NDC":"00002144501"},{"Id":385896,"FormularyType":"OHP","DrugName":"TALTZ INJ 80MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"80","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400D520","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML","NDC":"00002144509"},{"Id":385897,"FormularyType":"OHP","DrugName":"TALTZ INJ 80MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"80","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400D520","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML","NDC":"00002144511"},{"Id":385898,"FormularyType":"OHP","DrugName":"TALTZ INJ 80MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"80","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400D520","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML","NDC":"00002144527"},{"Id":385899,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 15MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D535","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 15 MG/0.5ML","NDC":"00002145701"},{"Id":385900,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 15MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D535","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 15 MG/0.5ML","NDC":"00002145780"},{"Id":385901,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 12.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D530","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 12.5 MG/0.5ML","NDC":"00002146001"},{"Id":385902,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 12.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D530","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 12.5 MG/0.5ML","NDC":"00002146080"},{"Id":385903,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 10MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D525","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 10 MG/0.5ML","NDC":"00002147101"},{"Id":385904,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 10MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D525","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 10 MG/0.5ML","NDC":"00002147180"},{"Id":385905,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 7.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D520","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 7.5 MG/0.5ML","NDC":"00002148401"},{"Id":385906,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 7.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D520","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 7.5 MG/0.5ML","NDC":"00002148480"},{"Id":385907,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 5MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D515","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 5 MG/0.5ML","NDC":"00002149501"},{"Id":385908,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 5MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D515","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 5 MG/0.5ML","NDC":"00002149580"},{"Id":385909,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 2.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D510","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 2.5 MG/0.5ML","NDC":"00002150601"},{"Id":385910,"FormularyType":"OHP","DrugName":"MOUNJARO INJ 2.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717308000D510","GenericName":"TIRZEPATIDE SOLN AUTO-INJECTOR 2.5 MG/0.5ML","NDC":"00002150680"},{"Id":385911,"FormularyType":"OHP","DrugName":"INLURIYO TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21403536700320","GenericName":"IMLUNESTRANT TOSYLATE TAB 200 MG","NDC":"00002171728"},{"Id":385912,"FormularyType":"OHP","DrugName":"INLURIYO TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21403536700320","GenericName":"IMLUNESTRANT TOSYLATE TAB 200 MG","NDC":"00002171756"},{"Id":385913,"FormularyType":"OHP","DrugName":"TRULICITY INJ 3/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D540","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 3 MG/0.5ML","NDC":"00002223601"},{"Id":385914,"FormularyType":"OHP","DrugName":"TRULICITY INJ 3/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D540","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 3 MG/0.5ML","NDC":"00002223680"},{"Id":385915,"FormularyType":"OHP","DrugName":"EMGALITY INJ 120MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203530E520","GenericName":"GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 120 MG/ML","NDC":"00002237701"},{"Id":385916,"FormularyType":"OHP","DrugName":"EMGALITY INJ 120MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203530E520","GenericName":"GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 120 MG/ML","NDC":"00002237711"},{"Id":385917,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 15/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D545","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 15 MG/0.5ML","NDC":"00002245701"},{"Id":385918,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 15/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D545","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 15 MG/0.5ML","NDC":"00002245780"},{"Id":385919,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 12.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D540","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 12.5 MG/0.5ML","NDC":"00002246001"},{"Id":385920,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 12.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D540","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 12.5 MG/0.5ML","NDC":"00002246080"},{"Id":385921,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 10/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D535","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 10 MG/0.5ML","NDC":"00002247101"},{"Id":385922,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 10/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D535","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 10 MG/0.5ML","NDC":"00002247180"},{"Id":385923,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 7.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D530","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 7.5 MG/0.5ML","NDC":"00002248401"},{"Id":385924,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 7.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D530","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 7.5 MG/0.5ML","NDC":"00002248480"},{"Id":385925,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 5/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D525","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 5 MG/0.5ML","NDC":"00002249501"},{"Id":385926,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 5/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D525","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 5 MG/0.5ML","NDC":"00002249580"},{"Id":385927,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 2.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D520","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 2.5 MG/0.5ML","NDC":"00002250601"},{"Id":385928,"FormularyType":"OHP","DrugName":"ZEPBOUND INJ 2.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125258000D520","GenericName":"TIRZEPATIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 2.5 MG/0.5ML","NDC":"00002250680"},{"Id":385929,"FormularyType":"OHP","DrugName":"EMGALITY INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203530E515","GenericName":"GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 100 MG/ML","NDC":"00002311501"},{"Id":385930,"FormularyType":"OHP","DrugName":"EMGALITY INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203530E515","GenericName":"GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 100 MG/ML","NDC":"00002311509"},{"Id":385931,"FormularyType":"OHP","DrugName":"OMVOH INJ 200/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250405040D525","GenericName":"MIRIKIZUMAB-MRKZ SUBCUTANEOUS SOLN AUTO-INJECTOR 200 MG/2ML","NDC":"00002311601"},{"Id":385932,"FormularyType":"OHP","DrugName":"OMVOH INJ 200/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250405040D525","GenericName":"MIRIKIZUMAB-MRKZ SUBCUTANEOUS SOLN AUTO-INJECTOR 200 MG/2ML","NDC":"00002311611"},{"Id":385933,"FormularyType":"OHP","DrugName":"TRULICITY INJ 4.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"4.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D550","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 4.5 MG/0.5ML","NDC":"00002318201"},{"Id":385934,"FormularyType":"OHP","DrugName":"TRULICITY INJ 4.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"4.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717001500D550","GenericName":"DULAGLUTIDE SOLN AUTO-INJECTOR 4.5 MG/0.5ML","NDC":"00002318280"},{"Id":385935,"FormularyType":"OHP","DrugName":"REYVOW TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406540600310","GenericName":"LASMIDITAN SUCCINATE TAB 50 MG","NDC":"00002431208"},{"Id":385936,"FormularyType":"OHP","DrugName":"VERZENIO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531010000305","GenericName":"ABEMACICLIB TAB 50 MG","NDC":"00002448354"},{"Id":385937,"FormularyType":"OHP","DrugName":"REYVOW TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406540600320","GenericName":"LASMIDITAN SUCCINATE TAB 100 MG","NDC":"00002449108"},{"Id":385938,"FormularyType":"OHP","DrugName":"VERZENIO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531010000310","GenericName":"ABEMACICLIB TAB 100 MG","NDC":"00002481554"},{"Id":385939,"FormularyType":"OHP","DrugName":"VERZENIO TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531010000315","GenericName":"ABEMACICLIB TAB 150 MG","NDC":"00002533754"},{"Id":385940,"FormularyType":"OHP","DrugName":"VERZENIO TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531010000320","GenericName":"ABEMACICLIB TAB 200 MG","NDC":"00002621654"},{"Id":385941,"FormularyType":"OHP","DrugName":"JAYPIRCA TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532165000320","GenericName":"PIRTOBRUTINIB TAB 50 MG","NDC":"00002690230"},{"Id":385942,"FormularyType":"OHP","DrugName":"JAYPIRCA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532165000330","GenericName":"PIRTOBRUTINIB TAB 100 MG","NDC":"00002702660"},{"Id":385943,"FormularyType":"OHP","DrugName":"HUMALOG INJ 100/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104005002022","GenericName":"INSULIN LISPRO INJ SOLN 100 UNIT/ML","NDC":"00002751001"},{"Id":385944,"FormularyType":"OHP","DrugName":"HUMALOG MIX SUS 75/25","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104080001820","GenericName":"INSULIN LISPRO PROT & LISPRO INJ 100 UNIT/ML (75-25)","NDC":"00002751101"},{"Id":385945,"FormularyType":"OHP","DrugName":"HUMALOG INJ 100/ML","DosageForm":"SOCT - Soln Cartridge","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500E220","GenericName":"INSULIN LISPRO SOLN CARTRIDGE 100 UNIT/ML","NDC":"00002751601"},{"Id":385946,"FormularyType":"OHP","DrugName":"HUMALOG INJ 100/ML","DosageForm":"SOCT - Soln Cartridge","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500E220","GenericName":"INSULIN LISPRO SOLN CARTRIDGE 100 UNIT/ML","NDC":"00002751659"},{"Id":385947,"FormularyType":"OHP","DrugName":"HUMALOG KWPN INJ 200/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D230","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 200 UNIT/ML","NDC":"00002771201"},{"Id":385948,"FormularyType":"OHP","DrugName":"HUMALOG KWPN INJ 200/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D230","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 200 UNIT/ML","NDC":"00002771227"},{"Id":385949,"FormularyType":"OHP","DrugName":"HUMALOG JR INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D221","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (0.5 UNIT DIAL)","NDC":"00002771401"},{"Id":385950,"FormularyType":"OHP","DrugName":"HUMALOG JR INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D221","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (0.5 UNIT DIAL)","NDC":"00002771459"},{"Id":385951,"FormularyType":"OHP","DrugName":"TALTZ INJ 80MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400E520","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 80 MG/ML","NDC":"00002772401"},{"Id":385952,"FormularyType":"OHP","DrugName":"TALTZ INJ 80MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400E520","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 80 MG/ML","NDC":"00002772411"},{"Id":385953,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ 100/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104005002022","GenericName":"INSULIN LISPRO INJ SOLN 100 UNIT/ML","NDC":"00002773701"},{"Id":385954,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ JR KWPN","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D221","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (0.5 UNIT DIAL)","NDC":"00002775201"},{"Id":385955,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ JR KWPN","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D221","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (0.5 UNIT DIAL)","NDC":"00002775205"},{"Id":385956,"FormularyType":"OHP","DrugName":"HUMATROPE INJ 6MG","DosageForm":"CART - Cartridge","Strength":"6","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E120","GenericName":"SOMATROPIN FOR INJ CARTRIDGE 6 MG (18 UNIT)","NDC":"00002814701"},{"Id":385957,"FormularyType":"OHP","DrugName":"HUMATROPE INJ 12MG","DosageForm":"CART - Cartridge","Strength":"12","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E130","GenericName":"SOMATROPIN FOR INJ CARTRIDGE 12 MG (36 UNIT)","NDC":"00002814801"},{"Id":385958,"FormularyType":"OHP","DrugName":"HUMATROPE INJ 24MG","DosageForm":"CART - Cartridge","Strength":"24","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E140","GenericName":"SOMATROPIN FOR INJ CARTRIDGE 24 MG","NDC":"00002814901"},{"Id":385959,"FormularyType":"OHP","DrugName":"HUMULIN R INJ U-100","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104010002005","GenericName":"INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML","NDC":"00002821501"},{"Id":385960,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00002822201"},{"Id":385961,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00002822259"},{"Id":385962,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ PROT KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710408000D320","GenericName":"INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25)","NDC":"00002823301"},{"Id":385963,"FormularyType":"OHP","DrugName":"INSULIN LISP INJ PROT KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710408000D320","GenericName":"INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25)","NDC":"00002823305"},{"Id":385964,"FormularyType":"OHP","DrugName":"HUMULIN N INJ U-100","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104020001805","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML","NDC":"00002831501"},{"Id":385965,"FormularyType":"OHP","DrugName":"HUMULIN INJ 70/30","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104090001810","GenericName":"INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30)","NDC":"00002871501"},{"Id":385966,"FormularyType":"OHP","DrugName":"HUMALOG MIX INJ 75/25KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710408000D320","GenericName":"INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25)","NDC":"00002879701"},{"Id":385967,"FormularyType":"OHP","DrugName":"HUMALOG MIX INJ 75/25KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710408000D320","GenericName":"INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25)","NDC":"00002879759"},{"Id":385968,"FormularyType":"OHP","DrugName":"HUMALOG MIX INJ 50/50KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710408000D340","GenericName":"INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (50-50)","NDC":"00002879801"},{"Id":385969,"FormularyType":"OHP","DrugName":"HUMALOG MIX INJ 50/50KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710408000D340","GenericName":"INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (50-50)","NDC":"00002879859"},{"Id":385970,"FormularyType":"OHP","DrugName":"HUMALOG KWPN INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00002879901"},{"Id":385971,"FormularyType":"OHP","DrugName":"HUMALOG KWPN INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00002879959"},{"Id":385972,"FormularyType":"OHP","DrugName":"HUMULIN INJ 70/30KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710409000D320","GenericName":"INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","NDC":"00002880301"},{"Id":385973,"FormularyType":"OHP","DrugName":"HUMULIN INJ 70/30KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710409000D320","GenericName":"INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","NDC":"00002880359"},{"Id":385974,"FormularyType":"OHP","DrugName":"HUMULIN N INJ U-100KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710402000D320","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML","NDC":"00002880501"},{"Id":385975,"FormularyType":"OHP","DrugName":"HUMULIN N INJ U-100KWP","DosageForm":"SUPN - Susp Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710402000D320","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML","NDC":"00002880559"},{"Id":385976,"FormularyType":"OHP","DrugName":"HUMULIN R INJ U-500KWP","DosageForm":"SOPN - Soln Pen-inj","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710401000D250","GenericName":"INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 500 UNIT/ML","NDC":"00002882401"},{"Id":385977,"FormularyType":"OHP","DrugName":"HUMULIN R INJ U-500KWP","DosageForm":"SOPN - Soln Pen-inj","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710401000D250","GenericName":"INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 500 UNIT/ML","NDC":"00002882427"},{"Id":385978,"FormularyType":"OHP","DrugName":"TALTZ INJ 20/0.25","DosageForm":"SOSY - Soln Pref Syr","Strength":"20","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400E510","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 20 MG/0.25ML","NDC":"00002890011"},{"Id":385979,"FormularyType":"OHP","DrugName":"TALTZ INJ 40/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025055400E515","GenericName":"IXEKIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 40 MG/0.5ML","NDC":"00002890511"},{"Id":385980,"FormularyType":"OHP","DrugName":"REZVOGLAR KP INJ 100UT/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400305D220","GenericName":"INSULIN GLARGINE-AGLR SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00002898001"},{"Id":385981,"FormularyType":"OHP","DrugName":"REZVOGLAR KP INJ 100UT/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400305D220","GenericName":"INSULIN GLARGINE-AGLR SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00002898005"},{"Id":385982,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370010000320","GenericName":"APIXABAN TAB 2.5 MG","NDC":"00003089321"},{"Id":385983,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370010000320","GenericName":"APIXABAN TAB 2.5 MG","NDC":"00003089331"},{"Id":385984,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370010000330","GenericName":"APIXABAN TAB 5 MG","NDC":"00003089421"},{"Id":385985,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370010000330","GenericName":"APIXABAN TAB 5 MG","NDC":"00003089431"},{"Id":385986,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370010000330","GenericName":"APIXABAN TAB 5 MG","NDC":"00003089470"},{"Id":385987,"FormularyType":"OHP","DrugName":"ELIQUIS CAP 0.15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"0.15","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"83370010006820","GenericName":"APIXABAN CAP SPRINKLE 0.15 MG","NDC":"00003089828"},{"Id":385988,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"83370010007330","GenericName":"APIXABAN TAB FOR ORAL SUSP PACK 4 X 0.5 MG (2 MG)","NDC":"00003102812"},{"Id":385989,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 0.5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"83370010007320","GenericName":"APIXABAN TAB FOR ORAL SUSP 0.5 MG","NDC":"00003102828"},{"Id":385990,"FormularyType":"OHP","DrugName":"ELIQUIS TAB 1.5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"83370010007325","GenericName":"APIXABAN TAB FOR ORAL SUSP PACK 3 X 0.5 MG (1.5 MG)","NDC":"00003102884"},{"Id":385991,"FormularyType":"OHP","DrugName":"BARACLUDE SOL","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12352030002020","GenericName":"ENTECAVIR ORAL SOLN 0.05 MG/ML","NDC":"00003161412"},{"Id":385992,"FormularyType":"OHP","DrugName":"REYATAZ POW 50MG","DosageForm":"PACK - Packet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515203020","GenericName":"ATAZANAVIR SULFATE ORAL POWDER PACKET 50 MG (BASE EQUIV)","NDC":"00003363810"},{"Id":385993,"FormularyType":"OHP","DrugName":"EVOTAZ TAB 300-150","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902220330","GenericName":"ATAZANAVIR SULFATE-COBICISTAT TAB 300-150 MG (BASE EQUIV)","NDC":"00003364111"},{"Id":385994,"FormularyType":"OHP","DrugName":"ELIQUIS ST P TAB 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8337001000B720","GenericName":"APIXABAN TAB STARTER PACK 5 MG","NDC":"00003376474"},{"Id":385995,"FormularyType":"OHP","DrugName":"AUGTYRO CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533865000120","GenericName":"REPOTRECTINIB CAP 40 MG","NDC":"00003404012"},{"Id":385996,"FormularyType":"OHP","DrugName":"AUGTYRO CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533865000120","GenericName":"REPOTRECTINIB CAP 40 MG","NDC":"00003404060"},{"Id":385997,"FormularyType":"OHP","DrugName":"AUGTYRO CAP 160MG","DosageForm":"CAPS - Capsule","Strength":"160","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533865000130","GenericName":"REPOTRECTINIB CAP 160 MG","NDC":"00003416014"},{"Id":385998,"FormularyType":"OHP","DrugName":"AUGTYRO CAP 160MG","DosageForm":"CAPS - Capsule","Strength":"160","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533865000130","GenericName":"REPOTRECTINIB CAP 160 MG","NDC":"00003416060"},{"Id":385999,"FormularyType":"OHP","DrugName":"TAMIFLU CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"O","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"00004080085"},{"Id":386000,"FormularyType":"OHP","DrugName":"TAMIFLU CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"O","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"00004080185"},{"Id":386001,"FormularyType":"OHP","DrugName":"TAMIFLU SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"O","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"00004082205"},{"Id":386002,"FormularyType":"OHP","DrugName":"TRUMENBA INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"1720004012E610","GenericName":"MENINGOCOCCAL GROUP B VAC (RECOMB) IM SUSP PREFILLED SYR","NDC":"00005010001"},{"Id":386003,"FormularyType":"OHP","DrugName":"TRUMENBA INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"1720004012E610","GenericName":"MENINGOCOCCAL GROUP B VAC (RECOMB) IM SUSP PREFILLED SYR","NDC":"00005010005"},{"Id":386004,"FormularyType":"OHP","DrugName":"TRUMENBA INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"1720004012E610","GenericName":"MENINGOCOCCAL GROUP B VAC (RECOMB) IM SUSP PREFILLED SYR","NDC":"00005010010"},{"Id":386005,"FormularyType":"OHP","DrugName":"CENTRUM SPEC PAK PRENATAL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006312","GenericName":"*PRENATAL W/FE FUM-FA TAB 27-0.8 MG & DHA CAP 200 MG PACK *","NDC":"00005180623"},{"Id":386006,"FormularyType":"OHP","DrugName":"PREVNAR 20 INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006540E620","GenericName":"PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE SUS PREF SYR 0.5 ML","NDC":"00005200002"},{"Id":386007,"FormularyType":"OHP","DrugName":"PREVNAR 20 INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006540E620","GenericName":"PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE SUS PREF SYR 0.5 ML","NDC":"00005200010"},{"Id":386008,"FormularyType":"OHP","DrugName":"CENTRUM SPEC PAK PRENATAL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006312","GenericName":"*PRENATAL W/FE FUM-FA TAB 27-0.8 MG & DHA CAP 200 MG PACK *","NDC":"00005436556"},{"Id":386009,"FormularyType":"OHP","DrugName":"ISENTRESS TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103060100320","GenericName":"RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV)","NDC":"00006022761"},{"Id":386010,"FormularyType":"OHP","DrugName":"ISENTRESS CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103060100510","GenericName":"RALTEGRAVIR POTASSIUM CHEW TAB 25 MG (BASE EQUIV)","NDC":"00006047361"},{"Id":386011,"FormularyType":"OHP","DrugName":"ISENTRESS CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103060100540","GenericName":"RALTEGRAVIR POTASSIUM CHEW TAB 100 MG (BASE EQUIV)","NDC":"00006047761"},{"Id":386012,"FormularyType":"OHP","DrugName":"ZOLINZA CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531575000120","GenericName":"VORINOSTAT CAP 100 MG","NDC":"00006056840"},{"Id":386013,"FormularyType":"OHP","DrugName":"EMEND SUS 125MG","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020001930","GenericName":"APREPITANT FOR ORAL SUSP 125 MG (125 MG/5ML)","NDC":"00006306601"},{"Id":386014,"FormularyType":"OHP","DrugName":"EMEND SUS 125MG","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020001930","GenericName":"APREPITANT FOR ORAL SUSP 125 MG (125 MG/5ML)","NDC":"00006306603"},{"Id":386015,"FormularyType":"OHP","DrugName":"PIFELTRO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109025000320","GenericName":"DORAVIRINE TAB 100 MG","NDC":"00006306901"},{"Id":386016,"FormularyType":"OHP","DrugName":"PREVYMIS TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045000320","GenericName":"LETERMOVIR TAB 240 MG","NDC":"00006307502"},{"Id":386017,"FormularyType":"OHP","DrugName":"PREVYMIS TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045000320","GenericName":"LETERMOVIR TAB 240 MG","NDC":"00006307503"},{"Id":386018,"FormularyType":"OHP","DrugName":"PREVYMIS TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045000320","GenericName":"LETERMOVIR TAB 240 MG","NDC":"00006307504"},{"Id":386019,"FormularyType":"OHP","DrugName":"PREVYMIS TAB 480MG","DosageForm":"TABS - Tablet","Strength":"480","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045000340","GenericName":"LETERMOVIR TAB 480 MG","NDC":"00006307602"},{"Id":386020,"FormularyType":"OHP","DrugName":"PREVYMIS TAB 480MG","DosageForm":"TABS - Tablet","Strength":"480","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045000340","GenericName":"LETERMOVIR TAB 480 MG","NDC":"00006307603"},{"Id":386021,"FormularyType":"OHP","DrugName":"PREVYMIS TAB 480MG","DosageForm":"TABS - Tablet","Strength":"480","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045000340","GenericName":"LETERMOVIR TAB 480 MG","NDC":"00006307604"},{"Id":386022,"FormularyType":"OHP","DrugName":"ISENTRESS HD TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103060100330","GenericName":"RALTEGRAVIR POTASSIUM TAB 600 MG (BASE EQUIV)","NDC":"00006308001"},{"Id":386023,"FormularyType":"OHP","DrugName":"ISENTRESS POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103060103020","GenericName":"RALTEGRAVIR POTASSIUM PACKET FOR SUSP 100 MG (BASE EQUIV)","NDC":"00006360361"},{"Id":386024,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 5MCG/0.5","DosageForm":"SUSY - Susp Pref Syr","Strength":"5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E610","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 5 MCG/0.5ML","NDC":"00006409301"},{"Id":386025,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 5MCG/0.5","DosageForm":"SUSY - Susp Pref Syr","Strength":"5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E610","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 5 MCG/0.5ML","NDC":"00006409302"},{"Id":386026,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 10MCG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E620","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 10 MCG/ML","NDC":"00006409401"},{"Id":386027,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 10MCG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E620","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 10 MCG/ML","NDC":"00006409402"},{"Id":386028,"FormularyType":"OHP","DrugName":"VAQTA INJ 25/0.5ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E602","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 25 UNIT/0.5ML","NDC":"00006409501"},{"Id":386029,"FormularyType":"OHP","DrugName":"VAQTA INJ 25/0.5ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E602","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 25 UNIT/0.5ML","NDC":"00006409502"},{"Id":386030,"FormularyType":"OHP","DrugName":"VAQTA INJ 50UNT/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E605","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 50 UNIT/ML","NDC":"00006409601"},{"Id":386031,"FormularyType":"OHP","DrugName":"VAQTA INJ 50UNT/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E605","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 50 UNIT/ML","NDC":"00006409602"},{"Id":386032,"FormularyType":"OHP","DrugName":"GARDASIL 9 INJ","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"45","AgeMaxUnit":"Y","GenericProductIdentifier":"17100065501800","GenericName":"HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC IM SUSP","NDC":"00006411901"},{"Id":386033,"FormularyType":"OHP","DrugName":"GARDASIL 9 INJ","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"45","AgeMaxUnit":"Y","GenericProductIdentifier":"17100065501800","GenericName":"HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC IM SUSP","NDC":"00006411903"},{"Id":386034,"FormularyType":"OHP","DrugName":"GARDASIL 9 INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"45","AgeMaxUnit":"Y","GenericProductIdentifier":"1710006550E600","GenericName":"HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC SUSP PREF SYR","NDC":"00006412101"},{"Id":386035,"FormularyType":"OHP","DrugName":"GARDASIL 9 INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"45","AgeMaxUnit":"Y","GenericProductIdentifier":"1710006550E600","GenericName":"HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC SUSP PREF SYR","NDC":"00006412102"},{"Id":386036,"FormularyType":"OHP","DrugName":"ERVEBO INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100004001800","GenericName":"EBOLA ZAIRE VIRUS VACCINE LIVE IM SUSP","NDC":"00006429301"},{"Id":386037,"FormularyType":"OHP","DrugName":"ERVEBO INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100004001800","GenericName":"EBOLA ZAIRE VIRUS VACCINE LIVE IM SUSP","NDC":"00006429302"},{"Id":386038,"FormularyType":"OHP","DrugName":"VAXNEUVANCE INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006535E620","GenericName":"PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE SUS PREF SYR 0.5 ML","NDC":"00006432903"},{"Id":386039,"FormularyType":"OHP","DrugName":"CAPVAXIVE INJ 0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006550E520","GenericName":"PNEUMOCOCCAL 21-VALENT CONJUGATE VACCINE SOLN PREF SYR 0.5ML","NDC":"00006434701"},{"Id":386040,"FormularyType":"OHP","DrugName":"CAPVAXIVE INJ 0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006550E520","GenericName":"PNEUMOCOCCAL 21-VALENT CONJUGATE VACCINE SOLN PREF SYR 0.5ML","NDC":"00006434702"},{"Id":386041,"FormularyType":"OHP","DrugName":"M-M-R II INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17109903102100","GenericName":"MEASLES-MUMPS-RUBELLA VIRUS VACCINES FOR INJ SOLN","NDC":"00006468100"},{"Id":386042,"FormularyType":"OHP","DrugName":"M-M-R II INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17109903102100","GenericName":"MEASLES-MUMPS-RUBELLA VIRUS VACCINES FOR INJ SOLN","NDC":"00006468101"},{"Id":386043,"FormularyType":"OHP","DrugName":"VARIVAX INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"1350","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100087101910","GenericName":"VARICELLA VIRUS VAC LIVE FOR INJ 1350 PFU/0.5ML","NDC":"00006482700"},{"Id":386044,"FormularyType":"OHP","DrugName":"VARIVAX INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"1350","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100087101910","GenericName":"VARICELLA VIRUS VAC LIVE FOR INJ 1350 PFU/0.5ML","NDC":"00006482701"},{"Id":386045,"FormularyType":"OHP","DrugName":"VAQTA INJ 25/0.5ML","DosageForm":"SUSP - Suspension","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100008001860","GenericName":"HEPATITIS A VACCINE INJ SUSP 25 UNIT/0.5ML","NDC":"00006483101"},{"Id":386046,"FormularyType":"OHP","DrugName":"VAQTA INJ 25/0.5ML","DosageForm":"SUSP - Suspension","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100008001860","GenericName":"HEPATITIS A VACCINE INJ SUSP 25 UNIT/0.5ML","NDC":"00006483141"},{"Id":386047,"FormularyType":"OHP","DrugName":"PNEUMOVAX 23 INJ 25/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006500E510","GenericName":"PNEUMOCOCCAL VACCINE POLYVALENT SOLN PREF SYR 25 MCG/0.5ML","NDC":"00006483701"},{"Id":386048,"FormularyType":"OHP","DrugName":"PNEUMOVAX 23 INJ 25/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720006500E510","GenericName":"PNEUMOCOCCAL VACCINE POLYVALENT SOLN PREF SYR 25 MCG/0.5ML","NDC":"00006483703"},{"Id":386049,"FormularyType":"OHP","DrugName":"VAQTA INJ 50UNT/ML","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100008001870","GenericName":"HEPATITIS A VACCINE INJ SUSP 50 UNIT/ML","NDC":"00006484100"},{"Id":386050,"FormularyType":"OHP","DrugName":"VAQTA INJ 50UNT/ML","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100008001870","GenericName":"HEPATITIS A VACCINE INJ SUSP 50 UNIT/ML","NDC":"00006484101"},{"Id":386051,"FormularyType":"OHP","DrugName":"VAQTA INJ 50UNT/ML","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100008001870","GenericName":"HEPATITIS A VACCINE INJ SUSP 50 UNIT/ML","NDC":"00006484141"},{"Id":386052,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 5MCG/0.5","DosageForm":"SUSP - Suspension","Strength":"5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201815","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 5 MCG/0.5ML","NDC":"00006498100"},{"Id":386053,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 5MCG/0.5","DosageForm":"SUSP - Suspension","Strength":"5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201815","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 5 MCG/0.5ML","NDC":"00006498101"},{"Id":386054,"FormularyType":"OHP","DrugName":"RECOMBIVA-HB INJ 40MCG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201840","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 40 MCG/ML","NDC":"00006499200"},{"Id":386055,"FormularyType":"OHP","DrugName":"RECOMBIVA-HB INJ 40MCG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201840","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 40 MCG/ML","NDC":"00006499201"},{"Id":386056,"FormularyType":"OHP","DrugName":"RECOMBIVA HB INJ 10MCG/ML","DosageForm":"SUSP - Suspension","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201820","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 10 MCG/ML","NDC":"00006499541"},{"Id":386057,"FormularyType":"OHP","DrugName":"DELSTRIGO TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903270320","GenericName":"DORAVIRINE-LAMIVUDINE-TENOFOVIR DF TAB 100-300-300 MG","NDC":"00006500701"},{"Id":386058,"FormularyType":"OHP","DrugName":"PREVYMIS PAK 120MG","DosageForm":"PACK - Packet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045003040","GenericName":"LETERMOVIR PELLET PACK 120 MG","NDC":"00006508501"},{"Id":386059,"FormularyType":"OHP","DrugName":"PREVYMIS PAK 120MG","DosageForm":"PACK - Packet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045003040","GenericName":"LETERMOVIR PELLET PACK 120 MG","NDC":"00006508599"},{"Id":386060,"FormularyType":"OHP","DrugName":"PREVYMIS PAK 20MG","DosageForm":"PACK - Packet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045003020","GenericName":"LETERMOVIR PELLET PACK 20 MG","NDC":"00006508601"},{"Id":386061,"FormularyType":"OHP","DrugName":"PREVYMIS PAK 20MG","DosageForm":"PACK - Packet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200045003020","GenericName":"LETERMOVIR PELLET PACK 20 MG","NDC":"00006508699"},{"Id":386062,"FormularyType":"OHP","DrugName":"WINREVAIR INJ 45MG","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ACTIVIN SIGNALING INHIBITOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40110070206430","GenericName":"SOTATERCEPT-CSRK FOR SUBCUTANEOUS SOLN KIT 2 X 45 MG","NDC":"00006508701"},{"Id":386063,"FormularyType":"OHP","DrugName":"WINREVAIR INJ 60MG","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ACTIVIN SIGNALING INHIBITOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40110070206435","GenericName":"SOTATERCEPT-CSRK FOR SUBCUTANEOUS SOLN KIT 2 X 60 MG","NDC":"00006508801"},{"Id":386064,"FormularyType":"OHP","DrugName":"WINREVAIR INJ 45MG","DosageForm":"KIT - Kit","Strength":"45","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ACTIVIN SIGNALING INHIBITOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40110070206420","GenericName":"SOTATERCEPT-CSRK FOR SUBCUTANEOUS SOLN KIT 45 MG","NDC":"00006509001"},{"Id":386065,"FormularyType":"OHP","DrugName":"WINREVAIR INJ 60MG","DosageForm":"KIT - Kit","Strength":"60","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ACTIVIN SIGNALING INHIBITOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40110070206425","GenericName":"SOTATERCEPT-CSRK FOR SUBCUTANEOUS SOLN KIT 60 MG","NDC":"00006509101"},{"Id":386066,"FormularyType":"OHP","DrugName":"WELIREG TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HYPOXIA-INDUCIBLE FACTOR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21421020000320","GenericName":"BELZUTIFAN TAB 40 MG","NDC":"00006533101"},{"Id":386067,"FormularyType":"OHP","DrugName":"STEGLATRO TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700055200320","GenericName":"ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 5 MG (BASE EQUIV)","NDC":"00006536303"},{"Id":386068,"FormularyType":"OHP","DrugName":"STEGLATRO TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700055200320","GenericName":"ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 5 MG (BASE EQUIV)","NDC":"00006536306"},{"Id":386069,"FormularyType":"OHP","DrugName":"STEGLATRO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700055200340","GenericName":"ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 15 MG (BASE EQUIV)","NDC":"00006536403"},{"Id":386070,"FormularyType":"OHP","DrugName":"STEGLATRO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700055200340","GenericName":"ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 15 MG (BASE EQUIV)","NDC":"00006536406"},{"Id":386071,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450310","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-500 MG","NDC":"00006536903"},{"Id":386072,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450310","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-500 MG","NDC":"00006536906"},{"Id":386073,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 7.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450330","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 7.5-500 MG","NDC":"00006537003"},{"Id":386074,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 7.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450330","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 7.5-500 MG","NDC":"00006537006"},{"Id":386075,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 2.5-1000","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450320","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-1000 MG","NDC":"00006537303"},{"Id":386076,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 2.5-1000","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450320","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-1000 MG","NDC":"00006537306"},{"Id":386077,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 7.5-1000","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450340","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 7.5-1000 MG","NDC":"00006537403"},{"Id":386078,"FormularyType":"OHP","DrugName":"SEGLUROMET TAB 7.5-1000","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002450340","GenericName":"ERTUGLIFLOZIN-METFORMIN HCL TAB 7.5-1000 MG","NDC":"00006537406"},{"Id":386079,"FormularyType":"OHP","DrugName":"TAZICEF INJ 1GM/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080122010","GenericName":"CEFTAZIDIME SODIUM IN DEXTROSE INJ 1 GM/50ML","NDC":"00007508804"},{"Id":386080,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 1000MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402165","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 1000 MG","NDC":"00009000501"},{"Id":386081,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 100MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"O","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402150","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 100 MG","NDC":"00009001103"},{"Id":386082,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 100MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"O","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402150","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 100 MG","NDC":"00009001104"},{"Id":386083,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402155","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 250 MG","NDC":"00009001305"},{"Id":386084,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402155","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 250 MG","NDC":"00009001306"},{"Id":386085,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402161","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 500 MG","NDC":"00009001612"},{"Id":386086,"FormularyType":"OHP","DrugName":"DEPO-ESTRADI INJ 5MG/ML","DosageForm":"OIL - Oil","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035101710","GenericName":"ESTRADIOL CYPIONATE IM IN OIL 5 MG/ML","NDC":"00009027101"},{"Id":386087,"FormularyType":"OHP","DrugName":"CLEOCIN PHOS INJ 9GM/60ML","DosageForm":"SOLN - Solution","Strength":"9","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020302034","GenericName":"CLINDAMYCIN PHOSPHATE INJ 9 GM/60ML","NDC":"00009072805"},{"Id":386088,"FormularyType":"OHP","DrugName":"CLEOCIN PHOS INJ 9GM/60ML","DosageForm":"SOLN - Solution","Strength":"9","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020302034","GenericName":"CLINDAMYCIN PHOSPHATE INJ 9 GM/60ML","NDC":"00009072809"},{"Id":386089,"FormularyType":"OHP","DrugName":"SOLU-CORTEF INJ 100MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"O","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402150","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 100 MG","NDC":"00009082501"},{"Id":386090,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 10MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002120","GenericName":"PEGVISOMANT FOR INJ 10 MG (AS PROTEIN)","NDC":"00009716601"},{"Id":386091,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 10MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002120","GenericName":"PEGVISOMANT FOR INJ 10 MG (AS PROTEIN)","NDC":"00009716630"},{"Id":386092,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 15MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002130","GenericName":"PEGVISOMANT FOR INJ 15 MG (AS PROTEIN)","NDC":"00009716801"},{"Id":386093,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 15MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002130","GenericName":"PEGVISOMANT FOR INJ 15 MG (AS PROTEIN)","NDC":"00009716830"},{"Id":386094,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 20MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002140","GenericName":"PEGVISOMANT FOR INJ 20 MG (AS PROTEIN)","NDC":"00009718801"},{"Id":386095,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 20MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002140","GenericName":"PEGVISOMANT FOR INJ 20 MG (AS PROTEIN)","NDC":"00009718830"},{"Id":386096,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 25MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002150","GenericName":"PEGVISOMANT FOR INJ 25 MG (AS PROTEIN)","NDC":"00009719901"},{"Id":386097,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 25MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002150","GenericName":"PEGVISOMANT FOR INJ 25 MG (AS PROTEIN)","NDC":"00009719930"},{"Id":386098,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 30MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002160","GenericName":"PEGVISOMANT FOR INJ 30 MG (AS PROTEIN)","NDC":"00009720001"},{"Id":386099,"FormularyType":"OHP","DrugName":"SOMAVERT INJ 30MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONE RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30180060002160","GenericName":"PEGVISOMANT FOR INJ 30 MG (AS PROTEIN)","NDC":"00009720030"},{"Id":386100,"FormularyType":"OHP","DrugName":"ESTRING MIS 7.5/24HR","DosageForm":"RING - Ring","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020009020","GenericName":"ESTRADIOL VAGINAL RING 2 MG (7.5 MCG/24HRS)","NDC":"00013104201"},{"Id":386101,"FormularyType":"OHP","DrugName":"GENOTROPIN INJ 5MG","DosageForm":"CART - Cartridge","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E159","GenericName":"SOMATROPIN FOR SUBCUTANEOUS INJ CARTRIDGE 5 MG","NDC":"00013262681"},{"Id":386102,"FormularyType":"OHP","DrugName":"GENOTROPIN INJ 12MG","DosageForm":"CART - Cartridge","Strength":"12","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E188","GenericName":"SOMATROPIN FOR SUBCUTANEOUS INJ CARTRIDGE 12 MG (36 UNIT)","NDC":"00013264681"},{"Id":386103,"FormularyType":"OHP","DrugName":"MD-GASTROVIE SOL 66-10%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94402015302050","GenericName":"DIATRIZOATE MEGLUMINE & SODIUM ORAL SOLN 66-10%","NDC":"00019481604"},{"Id":386104,"FormularyType":"OHP","DrugName":"UBRELVY TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000320","GenericName":"UBROGEPANT TAB 50 MG","NDC":"00023649801"},{"Id":386105,"FormularyType":"OHP","DrugName":"UBRELVY TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000320","GenericName":"UBROGEPANT TAB 50 MG","NDC":"00023649802"},{"Id":386106,"FormularyType":"OHP","DrugName":"UBRELVY TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000320","GenericName":"UBROGEPANT TAB 50 MG","NDC":"00023649810"},{"Id":386107,"FormularyType":"OHP","DrugName":"UBRELVY TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000340","GenericName":"UBROGEPANT TAB 100 MG","NDC":"00023650101"},{"Id":386108,"FormularyType":"OHP","DrugName":"UBRELVY TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000340","GenericName":"UBROGEPANT TAB 100 MG","NDC":"00023650102"},{"Id":386109,"FormularyType":"OHP","DrugName":"UBRELVY TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000340","GenericName":"UBROGEPANT TAB 100 MG","NDC":"00023650110"},{"Id":386110,"FormularyType":"OHP","DrugName":"UBRELVY TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701080000340","GenericName":"UBROGEPANT TAB 100 MG","NDC":"00023650116"},{"Id":386111,"FormularyType":"OHP","DrugName":"MULTAQ TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400028100320","GenericName":"DRONEDARONE HCL TAB 400 MG (BASE EQUIVALENT)","NDC":"00024414260"},{"Id":386112,"FormularyType":"OHP","DrugName":"SOLIQUA INJ 100/33","DosageForm":"SOPN - Soln Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2799100235D220","GenericName":"INSULIN GLARGINE-LIXISENATIDE SOL PEN-INJ 100-33 UNIT-MCG/ML","NDC":"00024576105"},{"Id":386113,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 300/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000E520","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 300 MG/2ML","NDC":"00024591400"},{"Id":386114,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 300/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000E520","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 300 MG/2ML","NDC":"00024591401"},{"Id":386115,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D520","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"00024591500"},{"Id":386116,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D520","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"00024591501"},{"Id":386117,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D520","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"00024591502"},{"Id":386118,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D520","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"00024591520"},{"Id":386119,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 200/1.14","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000E515","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML","NDC":"00024591800"},{"Id":386120,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 200/1.14","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000E515","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML","NDC":"00024591801"},{"Id":386121,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 200MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D515","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 200 MG/1.14ML","NDC":"00024591900"},{"Id":386122,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 200MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D515","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 200 MG/1.14ML","NDC":"00024591901"},{"Id":386123,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 200MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D515","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 200 MG/1.14ML","NDC":"00024591902"},{"Id":386124,"FormularyType":"OHP","DrugName":"DUPIXENT INJ 200MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027302000D515","GenericName":"DUPILUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 200 MG/1.14ML","NDC":"00024591920"},{"Id":386125,"FormularyType":"OHP","DrugName":"ADMELOG INJ 100U/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104005002022","GenericName":"INSULIN LISPRO INJ SOLN 100 UNIT/ML","NDC":"00024592410"},{"Id":386126,"FormularyType":"OHP","DrugName":"ADMELOG SOLO INJ 100U/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00024592500"},{"Id":386127,"FormularyType":"OHP","DrugName":"ADMELOG SOLO INJ 100U/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00024592501"},{"Id":386128,"FormularyType":"OHP","DrugName":"ADMELOG SOLO INJ 100U/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400500D222","GenericName":"INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL)","NDC":"00024592505"},{"Id":386129,"FormularyType":"OHP","DrugName":"ADMELOG INJ 100U/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104005002022","GenericName":"INSULIN LISPRO INJ SOLN 100 UNIT/ML","NDC":"00024592605"},{"Id":386130,"FormularyType":"OHP","DrugName":"NORPACE CAP 100MG CR","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010106910","GenericName":"DISOPYRAMIDE PHOSPHATE CAP ER 12HR 100 MG","NDC":"00025273231"},{"Id":386131,"FormularyType":"OHP","DrugName":"NORPACE CAP 150MG CR","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010106915","GenericName":"DISOPYRAMIDE PHOSPHATE CAP ER 12HR 150 MG","NDC":"00025274231"},{"Id":386132,"FormularyType":"OHP","DrugName":"CREON CAP 3000UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006705","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-9500-15000 UNIT","NDC":"00032004570"},{"Id":386133,"FormularyType":"OHP","DrugName":"CREON CAP 6000UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006720","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 6000-19000-30000 UNIT","NDC":"00032004670"},{"Id":386134,"FormularyType":"OHP","DrugName":"CREON CAP 12000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006740","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 12000-38000-60000 UNIT","NDC":"00032004770"},{"Id":386135,"FormularyType":"OHP","DrugName":"CREON CAP 3000UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006705","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-9500-15000 UNIT","NDC":"00032120370"},{"Id":386136,"FormularyType":"OHP","DrugName":"CREON CAP 24000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006760","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 24000-76000-120000 UNIT","NDC":"00032122401"},{"Id":386137,"FormularyType":"OHP","DrugName":"CREON CAP 24000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006760","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 24000-76000-120000 UNIT","NDC":"00032263601"},{"Id":386138,"FormularyType":"OHP","DrugName":"CREON CAP 36000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006780","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 36000-114000-180000 UNIT","NDC":"00032263701"},{"Id":386139,"FormularyType":"OHP","DrugName":"CREON CAP 36000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006780","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 36000-114000-180000 UNIT","NDC":"00032301613"},{"Id":386140,"FormularyType":"OHP","DrugName":"CORTIFOAM AER 90MG","DosageForm":"FOAM - Foam","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010103905","GenericName":"HYDROCORTISONE ACETATE PERIANAL FOAM 10% (90 MG/DOSE)","NDC":"00037683015"},{"Id":386141,"FormularyType":"OHP","DrugName":"TYLENOL CAP 325MG","DosageForm":"CAPS - Capsule","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000110","GenericName":"ACETAMINOPHEN CAP 325 MG","NDC":"00045048720"},{"Id":386142,"FormularyType":"OHP","DrugName":"TYLENOL CAP 325MG","DosageForm":"CAPS - Capsule","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000110","GenericName":"ACETAMINOPHEN CAP 325 MG","NDC":"00045048790"},{"Id":386143,"FormularyType":"OHP","DrugName":"TYLENOL CHIL CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00045051824"},{"Id":386144,"FormularyType":"OHP","DrugName":"TYLENOL CHIL CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00045051924"},{"Id":386145,"FormularyType":"OHP","DrugName":"BCG VACCINE INJ 50MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200010002150","GenericName":"BCG VACCINE FOR INJ SOLN 50 MG","NDC":"00052060301"},{"Id":386146,"FormularyType":"OHP","DrugName":"BCG VACCINE INJ 50MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200010002150","GenericName":"BCG VACCINE FOR INJ SOLN 50 MG","NDC":"00052060302"},{"Id":386147,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"00054000713"},{"Id":386148,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"00054000725"},{"Id":386149,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"00054001020"},{"Id":386150,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"00054001021"},{"Id":386151,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"00054001025"},{"Id":386152,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"00054001120"},{"Id":386153,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"00054001121"},{"Id":386154,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"00054001125"},{"Id":386155,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"00054001221"},{"Id":386156,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"00054001225"},{"Id":386157,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00054001720"},{"Id":386158,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00054001725"},{"Id":386159,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00054001729"},{"Id":386160,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"00054001920"},{"Id":386161,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"00054001925"},{"Id":386162,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"00054004544"},{"Id":386163,"FormularyType":"OHP","DrugName":"DIGOXIN SOL 50MCG/ML","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"O","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010002040","GenericName":"DIGOXIN ORAL SOLN 0.05 MG/ML","NDC":"00054005746"},{"Id":386164,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"00054006447"},{"Id":386165,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"00054007725"},{"Id":386166,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"00054007729"},{"Id":386167,"FormularyType":"OHP","DrugName":"BALSALAZIDE CAP 750MG","DosageForm":"CAPS - Capsule","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500020100120","GenericName":"BALSALAZIDE DISODIUM CAP 750 MG","NDC":"00054007928"},{"Id":386168,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000120","GenericName":"ZALEPLON CAP 5 MG","NDC":"00054008425"},{"Id":386169,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000130","GenericName":"ZALEPLON CAP 10 MG","NDC":"00054008525"},{"Id":386170,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"00054008813"},{"Id":386171,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"00054008826"},{"Id":386172,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000310","GenericName":"ACARBOSE TAB 25 MG","NDC":"00054014025"},{"Id":386173,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000320","GenericName":"ACARBOSE TAB 50 MG","NDC":"00054014125"},{"Id":386174,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000340","GenericName":"ACARBOSE TAB 100 MG","NDC":"00054014225"},{"Id":386175,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00054016325"},{"Id":386176,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00054016329"},{"Id":386177,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"00054016625"},{"Id":386178,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"00054016629"},{"Id":386179,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"00054017613"},{"Id":386180,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"00054017713"},{"Id":386181,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"00054018813"},{"Id":386182,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"00054018913"},{"Id":386183,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100310","GenericName":"MORPHINE SULFATE TAB 15 MG","NDC":"00054023524"},{"Id":386184,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100310","GenericName":"MORPHINE SULFATE TAB 15 MG","NDC":"00054023525"},{"Id":386185,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100315","GenericName":"MORPHINE SULFATE TAB 30 MG","NDC":"00054023624"},{"Id":386186,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100315","GenericName":"MORPHINE SULFATE TAB 30 MG","NDC":"00054023625"},{"Id":386187,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"00054023749"},{"Id":386188,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"00054023763"},{"Id":386189,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 20MG/5ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102070","GenericName":"MORPHINE SULFATE ORAL SOLN 20 MG/5ML","NDC":"00054023849"},{"Id":386190,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 20MG/5ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102070","GenericName":"MORPHINE SULFATE ORAL SOLN 20 MG/5ML","NDC":"00054023863"},{"Id":386191,"FormularyType":"OHP","DrugName":"CODEINE SULF TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100020200310","GenericName":"CODEINE SULFATE TAB 30 MG","NDC":"00054024424"},{"Id":386192,"FormularyType":"OHP","DrugName":"CODEINE SULF TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100020200310","GenericName":"CODEINE SULFATE TAB 30 MG","NDC":"00054024425"},{"Id":386193,"FormularyType":"OHP","DrugName":"CODEINE SULF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100020200315","GenericName":"CODEINE SULFATE TAB 60 MG","NDC":"00054024525"},{"Id":386194,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"00054025413"},{"Id":386195,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"00054025422"},{"Id":386196,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"00054025513"},{"Id":386197,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"00054025522"},{"Id":386198,"FormularyType":"OHP","DrugName":"NARATRIPTAN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406050100310","GenericName":"NARATRIPTAN HCL TAB 1 MG (BASE EQUIV)","NDC":"00054027803"},{"Id":386199,"FormularyType":"OHP","DrugName":"NARATRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406050100320","GenericName":"NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV)","NDC":"00054027903"},{"Id":386200,"FormularyType":"OHP","DrugName":"LINEZOLID SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040001920","GenericName":"LINEZOLID FOR SUSP 100 MG/5ML","NDC":"00054031950"},{"Id":386201,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 100/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708020","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/ACT","NDC":"00054032656"},{"Id":386202,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 250/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708030","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/ACT","NDC":"00054032756"},{"Id":386203,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 500/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708040","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/ACT","NDC":"00054032856"},{"Id":386204,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"00054037025"},{"Id":386205,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"00054037125"},{"Id":386206,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"00054037225"},{"Id":386207,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"00054037325"},{"Id":386208,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"00054037425"},{"Id":386209,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"00054037525"},{"Id":386210,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"O","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000105","GenericName":"CYCLOPHOSPHAMIDE CAP 25 MG","NDC":"00054038225"},{"Id":386211,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"O","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000110","GenericName":"CYCLOPHOSPHAMIDE CAP 50 MG","NDC":"00054038325"},{"Id":386212,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00054039041"},{"Id":386213,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00054039063"},{"Id":386214,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"00054041313"},{"Id":386215,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"00054041413"},{"Id":386216,"FormularyType":"OHP","DrugName":"POSACONAZOLE SUS 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060001820","GenericName":"POSACONAZOLE SUSP 40 MG/ML","NDC":"00054044949"},{"Id":386217,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"00054047021"},{"Id":386218,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"00054047121"},{"Id":386219,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"00054047221"},{"Id":386220,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"00054048013"},{"Id":386221,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"00054048113"},{"Id":386222,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"00054048213"},{"Id":386223,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"00054049713"},{"Id":386224,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"00054050823"},{"Id":386225,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00054051741"},{"Id":386226,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00054051744"},{"Id":386227,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00054051750"},{"Id":386228,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"00054060421"},{"Id":386229,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 0.5GM","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100110","GenericName":"ICOSAPENT ETHYL CAP 0.5 GM","NDC":"00054062127"},{"Id":386230,"FormularyType":"OHP","DrugName":"DICYCLOMINE SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010102050","GenericName":"DICYCLOMINE HCL ORAL SOLN 10 MG/5ML","NDC":"00054062263"},{"Id":386231,"FormularyType":"OHP","DrugName":"VIGABATRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085000320","GenericName":"VIGABATRIN TAB 500 MG","NDC":"00054065225"},{"Id":386232,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"00054066025"},{"Id":386233,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"00054074287"},{"Id":386234,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00054074825"},{"Id":386235,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00054074831"},{"Id":386236,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"00054081221"},{"Id":386237,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"00054081222"},{"Id":386238,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"00054081225"},{"Id":386239,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"00054081229"},{"Id":386240,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"00054082925"},{"Id":386241,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"00054083025"},{"Id":386242,"FormularyType":"OHP","DrugName":"SAPROPTERIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565100320","GenericName":"SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG","NDC":"00054090623"},{"Id":386243,"FormularyType":"OHP","DrugName":"CALCITRIOL SOL 1MCG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030002050","GenericName":"CALCITRIOL ORAL SOLN 1 MCG/ML","NDC":"00054312041"},{"Id":386244,"FormularyType":"OHP","DrugName":"DEXAMETHASON CON 1MG/ML","DosageForm":"CONC - Concentrate","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020001320","GenericName":"DEXAMETHASONE CONC 1 MG/ML","NDC":"00054317644"},{"Id":386245,"FormularyType":"OHP","DrugName":"DEXAMETHASON SOL 0.5/5ML","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020002005","GenericName":"DEXAMETHASONE SOLN 0.5 MG/5ML","NDC":"00054317757"},{"Id":386246,"FormularyType":"OHP","DrugName":"DEXAMETHASON SOL 0.5/5ML","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020002005","GenericName":"DEXAMETHASONE SOLN 0.5 MG/5ML","NDC":"00054317763"},{"Id":386247,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP LIQ 2.5/5","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100910","GenericName":"DIPHENOXYLATE W/ ATROPINE LIQ 2.5-0.025 MG/5ML","NDC":"00054319446"},{"Id":386248,"FormularyType":"OHP","DrugName":"FLUTICASONE SPR 50MCG","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200032301810","GenericName":"FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT","NDC":"00054327099"},{"Id":386249,"FormularyType":"OHP","DrugName":"FUROSEMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002050","GenericName":"FUROSEMIDE ORAL SOLN 10 MG/ML","NDC":"00054329446"},{"Id":386250,"FormularyType":"OHP","DrugName":"FUROSEMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002050","GenericName":"FUROSEMIDE ORAL SOLN 10 MG/ML","NDC":"00054329450"},{"Id":386251,"FormularyType":"OHP","DrugName":"FUROSEMIDE SOL 40MG/5ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002045","GenericName":"FUROSEMIDE ORAL SOLN 8 MG/ML","NDC":"00054329863"},{"Id":386252,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% VISC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"00054350049"},{"Id":386253,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"00054350547"},{"Id":386254,"FormularyType":"OHP","DrugName":"PREDNISONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045002005","GenericName":"PREDNISONE ORAL SOLN 5 MG/5ML","NDC":"00054372250"},{"Id":386255,"FormularyType":"OHP","DrugName":"PREDNISONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045002005","GenericName":"PREDNISONE ORAL SOLN 5 MG/5ML","NDC":"00054372263"},{"Id":386256,"FormularyType":"OHP","DrugName":"PROPRANOLOL SOL 20MG/5ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"33100040102050","GenericName":"PROPRANOLOL HCL ORAL SOLN 20 MG/5ML","NDC":"00054372763"},{"Id":386257,"FormularyType":"OHP","DrugName":"PROPRANOLOL SOL 40MG/5ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"33100040102060","GenericName":"PROPRANOLOL HCL ORAL SOLN 40 MG/5ML","NDC":"00054373063"},{"Id":386258,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"00054414622"},{"Id":386259,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"00054414623"},{"Id":386260,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"00054417925"},{"Id":386261,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"00054418025"},{"Id":386262,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000325","GenericName":"DEXAMETHASONE TAB 1 MG","NDC":"00054418125"},{"Id":386263,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"00054418225"},{"Id":386264,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"00054418325"},{"Id":386265,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"00054418425"},{"Id":386266,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"00054418625"},{"Id":386267,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"00054429725"},{"Id":386268,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"00054429731"},{"Id":386269,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"00054429925"},{"Id":386270,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"00054429931"},{"Id":386271,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"00054430125"},{"Id":386272,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"00054430129"},{"Id":386273,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00054449613"},{"Id":386274,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00054449625"},{"Id":386275,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"00054449705"},{"Id":386276,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"00054449710"},{"Id":386277,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100335","GenericName":"LEUCOVORIN CALCIUM TAB 15 MG","NDC":"00054449810"},{"Id":386278,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100345","GenericName":"LEUCOVORIN CALCIUM TAB 25 MG","NDC":"00054449911"},{"Id":386279,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"00054455025"},{"Id":386280,"FormularyType":"OHP","DrugName":"MERCAPTOPUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300040000305","GenericName":"MERCAPTOPURINE TAB 50 MG","NDC":"00054458111"},{"Id":386281,"FormularyType":"OHP","DrugName":"MERCAPTOPUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300040000305","GenericName":"MERCAPTOPURINE TAB 50 MG","NDC":"00054458127"},{"Id":386282,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00054472825"},{"Id":386283,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00054472831"},{"Id":386284,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"00054474125"},{"Id":386285,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"00054474131"},{"Id":386286,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"00054474225"},{"Id":386287,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000325","GenericName":"DEXAMETHASONE TAB 1 MG","NDC":"00054817425"},{"Id":386288,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"00054817525"},{"Id":386289,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"00054817625"},{"Id":386290,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"00054817925"},{"Id":386291,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"00054818025"},{"Id":386292,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"00054818125"},{"Id":386293,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"00054818325"},{"Id":386294,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"00054829725"},{"Id":386295,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"00054829925"},{"Id":386296,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"00054830125"},{"Id":386297,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00054849619"},{"Id":386298,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00054872425"},{"Id":386299,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"00054873925"},{"Id":386300,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"00054874025"},{"Id":386301,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00054981725"},{"Id":386302,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00054981729"},{"Id":386303,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00054982825"},{"Id":386304,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00054982831"},{"Id":386305,"FormularyType":"OHP","DrugName":"CYCLOMYDRIL SOL OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86359902102010","GenericName":"CYCLOPENTOLATE W/ PHENYLEPHRINE OPHTH SOLN 0.2-1%","NDC":"00065035902"},{"Id":386306,"FormularyType":"OHP","DrugName":"CYCLOMYDRIL SOL OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86359902102010","GenericName":"CYCLOPENTOLATE W/ PHENYLEPHRINE OPHTH SOLN 0.2-1%","NDC":"00065035905"},{"Id":386307,"FormularyType":"OHP","DrugName":"CYCLOGYL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350020102005","GenericName":"CYCLOPENTOLATE HCL OPHTH SOLN 0.5%","NDC":"00065039515"},{"Id":386308,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"00065081701"},{"Id":386309,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"00065081702"},{"Id":386310,"FormularyType":"OHP","DrugName":"NUTREN LIQ JUNIOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"00065904390"},{"Id":386311,"FormularyType":"OHP","DrugName":"NUTREN LIQ JR/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"00065904570"},{"Id":386312,"FormularyType":"OHP","DrugName":"NUTREN LIQ JR/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"00065904590"},{"Id":386313,"FormularyType":"OHP","DrugName":"EX-LAX CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"00067000524"},{"Id":386314,"FormularyType":"OHP","DrugName":"EX-LAX CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"00067000548"},{"Id":386315,"FormularyType":"OHP","DrugName":"EX-LAX TAB MAX ST","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"00067001624"},{"Id":386316,"FormularyType":"OHP","DrugName":"EX-LAX TAB MAX ST","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"00067001648"},{"Id":386317,"FormularyType":"OHP","DrugName":"PERDIEM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200315","GenericName":"SENNOSIDES TAB 15 MG","NDC":"00067069660"},{"Id":386318,"FormularyType":"OHP","DrugName":"SLOW FE TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"00067434730"},{"Id":386319,"FormularyType":"OHP","DrugName":"SLOW FE TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"00067434760"},{"Id":386320,"FormularyType":"OHP","DrugName":"SLOW FE TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"00067434772"},{"Id":386321,"FormularyType":"OHP","DrugName":"SLOW FE TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"00067434790"},{"Id":386322,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00067488014"},{"Id":386323,"FormularyType":"OHP","DrugName":"NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00067489007"},{"Id":386324,"FormularyType":"OHP","DrugName":"NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00067489014"},{"Id":386325,"FormularyType":"OHP","DrugName":"NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00067490007"},{"Id":386326,"FormularyType":"OHP","DrugName":"NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00067490014"},{"Id":386327,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00067606220"},{"Id":386328,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00067606910"},{"Id":386329,"FormularyType":"OHP","DrugName":"SENNA SMOOTH TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200315","GenericName":"SENNOSIDES TAB 15 MG","NDC":"00067624024"},{"Id":386330,"FormularyType":"OHP","DrugName":"EX-LAX CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"00067814002"},{"Id":386331,"FormularyType":"OHP","DrugName":"EX-LAX CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"00067814003"},{"Id":386332,"FormularyType":"OHP","DrugName":"EX-LAX TAB MAX ST","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"00067814201"},{"Id":386333,"FormularyType":"OHP","DrugName":"EX-LAX TAB MAX ST","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"00067814202"},{"Id":386334,"FormularyType":"OHP","DrugName":"PERDIEM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200315","GenericName":"SENNOSIDES TAB 15 MG","NDC":"00067814301"},{"Id":386335,"FormularyType":"OHP","DrugName":"BOSULIF TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531812000320","GenericName":"BOSUTINIB TAB 100 MG","NDC":"00069013501"},{"Id":386336,"FormularyType":"OHP","DrugName":"BOSULIF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531812000340","GenericName":"BOSUTINIB TAB 500 MG","NDC":"00069013601"},{"Id":386337,"FormularyType":"OHP","DrugName":"INLYTA TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21335013000320","GenericName":"AXITINIB TAB 1 MG","NDC":"00069014501"},{"Id":386338,"FormularyType":"OHP","DrugName":"INLYTA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21335013000340","GenericName":"AXITINIB TAB 5 MG","NDC":"00069015111"},{"Id":386339,"FormularyType":"OHP","DrugName":"IBRANCE CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000120","GenericName":"PALBOCICLIB CAP 75 MG","NDC":"00069018721"},{"Id":386340,"FormularyType":"OHP","DrugName":"IBRANCE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000130","GenericName":"PALBOCICLIB CAP 100 MG","NDC":"00069018821"},{"Id":386341,"FormularyType":"OHP","DrugName":"IBRANCE CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000140","GenericName":"PALBOCICLIB CAP 125 MG","NDC":"00069018921"},{"Id":386342,"FormularyType":"OHP","DrugName":"BOSULIF TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531812000327","GenericName":"BOSUTINIB TAB 400 MG","NDC":"00069019301"},{"Id":386343,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 2500/0.2","DosageForm":"SOSY - Soln Pref Syr","Strength":"2500","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E505","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 2500 UNIT/0.2ML","NDC":"00069019501"},{"Id":386344,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 2500/0.2","DosageForm":"SOSY - Soln Pref Syr","Strength":"2500","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E505","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 2500 UNIT/0.2ML","NDC":"00069019502"},{"Id":386345,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 5000/0.2","DosageForm":"SOSY - Soln Pref Syr","Strength":"5000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E515","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 5000 UNIT/0.2ML","NDC":"00069019601"},{"Id":386346,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 5000/0.2","DosageForm":"SOSY - Soln Pref Syr","Strength":"5000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E515","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 5000 UNIT/0.2ML","NDC":"00069019602"},{"Id":386347,"FormularyType":"OHP","DrugName":"VIZIMPRO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360019000320","GenericName":"DACOMITINIB TAB 15 MG","NDC":"00069019730"},{"Id":386348,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 7500/0.3","DosageForm":"SOSY - Soln Pref Syr","Strength":"7500","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E520","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 7500 UNIT/0.3ML","NDC":"00069020601"},{"Id":386349,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 7500/0.3","DosageForm":"SOSY - Soln Pref Syr","Strength":"7500","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E520","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 7500 UNIT/0.3ML","NDC":"00069020602"},{"Id":386350,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 10000/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E530","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 10000 UNIT/ML","NDC":"00069021701"},{"Id":386351,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 10000/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E530","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 10000 UNIT/ML","NDC":"00069021702"},{"Id":386352,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 12500UNT","DosageForm":"SOSY - Soln Pref Syr","Strength":"12500","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E535","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 12500 UNIT/0.5ML","NDC":"00069022001"},{"Id":386353,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 12500UNT","DosageForm":"SOSY - Soln Pref Syr","Strength":"12500","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E535","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 12500 UNIT/0.5ML","NDC":"00069022002"},{"Id":386354,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 15000UNT","DosageForm":"SOSY - Soln Pref Syr","Strength":"15000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E540","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 15000 UNIT/0.6ML","NDC":"00069022301"},{"Id":386355,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 15000UNT","DosageForm":"SOSY - Soln Pref Syr","Strength":"15000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E540","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 15000 UNIT/0.6ML","NDC":"00069022302"},{"Id":386356,"FormularyType":"OHP","DrugName":"LORBRENA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530556000320","GenericName":"LORLATINIB TAB 25 MG","NDC":"00069022701"},{"Id":386357,"FormularyType":"OHP","DrugName":"LORBRENA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530556000320","GenericName":"LORLATINIB TAB 25 MG","NDC":"00069022703"},{"Id":386358,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 18000UNT","DosageForm":"SOSY - Soln Pref Syr","Strength":"18000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E550","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 18000 UNIT/0.72ML","NDC":"00069022801"},{"Id":386359,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 18000UNT","DosageForm":"SOSY - Soln Pref Syr","Strength":"18000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310101010E550","GenericName":"DALTEPARIN SODIUM SOLN PREFILLED SYR 18000 UNIT/0.72ML","NDC":"00069022802"},{"Id":386360,"FormularyType":"OHP","DrugName":"LORBRENA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530556000330","GenericName":"LORLATINIB TAB 100 MG","NDC":"00069023101"},{"Id":386361,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 95000UNT","DosageForm":"SOLN - Solution","Strength":"95000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101010102080","GenericName":"DALTEPARIN SODIUM SUBCUTANEOUS SOLN 95000 UNIT/3.8ML","NDC":"00069023201"},{"Id":386362,"FormularyType":"OHP","DrugName":"TALZENNA CAP 0.1MG","DosageForm":"CAPS - Capsule","Strength":"0.1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535580400105","GenericName":"TALAZOPARIB TOSYLATE CAP 0.1 MG (BASE EQUIVALENT)","NDC":"00069025230"},{"Id":386363,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 2500/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101010102017","GenericName":"DALTEPARIN SODIUM SUBCUTANEOUS SOLN 10000 UNIT/4ML","NDC":"00069025301"},{"Id":386364,"FormularyType":"OHP","DrugName":"FRAGMIN INJ 2500/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101010102017","GenericName":"DALTEPARIN SODIUM SUBCUTANEOUS SOLN 10000 UNIT/4ML","NDC":"00069025310"},{"Id":386365,"FormularyType":"OHP","DrugName":"IBRANCE TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000320","GenericName":"PALBOCICLIB TAB 75 MG","NDC":"00069028403"},{"Id":386366,"FormularyType":"OHP","DrugName":"IBRANCE TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000320","GenericName":"PALBOCICLIB TAB 75 MG","NDC":"00069028407"},{"Id":386367,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 300/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240152010E520","GenericName":"FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 300 MCG/0.5ML","NDC":"00069029101"},{"Id":386368,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 300/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240152010E520","GenericName":"FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 300 MCG/0.5ML","NDC":"00069029110"},{"Id":386369,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 480/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"480","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240152010E530","GenericName":"FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 480 MCG/0.8ML","NDC":"00069029201"},{"Id":386370,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 480/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"480","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240152010E530","GenericName":"FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 480 MCG/0.8ML","NDC":"00069029210"},{"Id":386371,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 300MCG","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401520102020","GenericName":"FILGRASTIM-AAFI INJ 300 MCG/ML","NDC":"00069029301"},{"Id":386372,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 300MCG","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401520102020","GenericName":"FILGRASTIM-AAFI INJ 300 MCG/ML","NDC":"00069029310"},{"Id":386373,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 480MCG","DosageForm":"SOLN - Solution","Strength":"480","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401520102030","GenericName":"FILGRASTIM-AAFI INJ 480 MCG/1.6ML (300 MCG/ML)","NDC":"00069029401"},{"Id":386374,"FormularyType":"OHP","DrugName":"NIVESTYM INJ 480MCG","DosageForm":"SOLN - Solution","Strength":"480","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401520102030","GenericName":"FILGRASTIM-AAFI INJ 480 MCG/1.6ML (300 MCG/ML)","NDC":"00069029410"},{"Id":386375,"FormularyType":"OHP","DrugName":"TICOVAC INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"1.2","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710008610E610","GenericName":"TICK-BORNE ENCEPHALIT VAC INACT SUSP PREF SYR 1.2 MCG/0.25ML","NDC":"00069029702"},{"Id":386376,"FormularyType":"OHP","DrugName":"DAURISMO TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21370030300320","GenericName":"GLASDEGIB MALEATE TAB 25 MG (BASE EQUIVALENT)","NDC":"00069029860"},{"Id":386377,"FormularyType":"OHP","DrugName":"TALZENNA CAP 0.25MG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535580400110","GenericName":"TALAZOPARIB TOSYLATE CAP 0.25 MG (BASE EQUIVALENT)","NDC":"00069035330"},{"Id":386378,"FormularyType":"OHP","DrugName":"TICOVAC INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"2.4","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710008610E620","GenericName":"TICK-BORNE ENCEPHALIT VAC INACT SUSP PREF SYR 2.4 MCG/0.5ML","NDC":"00069041102"},{"Id":386379,"FormularyType":"OHP","DrugName":"TICOVAC INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"2.4","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710008610E620","GenericName":"TICK-BORNE ENCEPHALIT VAC INACT SUSP PREF SYR 2.4 MCG/0.5ML","NDC":"00069041110"},{"Id":386380,"FormularyType":"OHP","DrugName":"TALZENNA CAP 0.35MG","DosageForm":"CAPS - Capsule","Strength":"0.35","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535580400112","GenericName":"TALAZOPARIB TOSYLATE CAP 0.35 MG (BASE EQUIVALENT)","NDC":"00069045430"},{"Id":386381,"FormularyType":"OHP","DrugName":"IBRANCE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000330","GenericName":"PALBOCICLIB TAB 100 MG","NDC":"00069048603"},{"Id":386382,"FormularyType":"OHP","DrugName":"IBRANCE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000330","GenericName":"PALBOCICLIB TAB 100 MG","NDC":"00069048607"},{"Id":386383,"FormularyType":"OHP","DrugName":"XELJANZ XR TAB 11MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"11","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065107530","GenericName":"TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT)","NDC":"00069050130"},{"Id":386384,"FormularyType":"OHP","DrugName":"XELJANZ XR TAB 22MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"22","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065107550","GenericName":"TOFACITINIB CITRATE TAB ER 24HR 22 MG (BASE EQUIVALENT)","NDC":"00069050230"},{"Id":386385,"FormularyType":"OHP","DrugName":"BOSULIF CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531812000120","GenericName":"BOSUTINIB CAP 50 MG","NDC":"00069050430"},{"Id":386386,"FormularyType":"OHP","DrugName":"TALZENNA CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535580400114","GenericName":"TALAZOPARIB TOSYLATE CAP 0.5 MG (BASE EQUIVALENT)","NDC":"00069054630"},{"Id":386387,"FormularyType":"OHP","DrugName":"PENBRAYA INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040601900","GenericName":"MENINGOCOCCAL ACYW (TET CONJ)-MENING B (RCMB) VACC FOR INJ","NDC":"00069060001"},{"Id":386388,"FormularyType":"OHP","DrugName":"PENBRAYA INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040601900","GenericName":"MENINGOCOCCAL ACYW (TET CONJ)-MENING B (RCMB) VACC FOR INJ","NDC":"00069060005"},{"Id":386389,"FormularyType":"OHP","DrugName":"PENBRAYA INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040601900","GenericName":"MENINGOCOCCAL ACYW (TET CONJ)-MENING B (RCMB) VACC FOR INJ","NDC":"00069060010"},{"Id":386390,"FormularyType":"OHP","DrugName":"TALZENNA CAP 0.75MG","DosageForm":"CAPS - Capsule","Strength":"0.75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535580400118","GenericName":"TALAZOPARIB TOSYLATE CAP 0.75 MG (BASE EQUIVALENT)","NDC":"00069065530"},{"Id":386391,"FormularyType":"OHP","DrugName":"IBRANCE TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000340","GenericName":"PALBOCICLIB TAB 125 MG","NDC":"00069068803"},{"Id":386392,"FormularyType":"OHP","DrugName":"IBRANCE TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531060000340","GenericName":"PALBOCICLIB TAB 125 MG","NDC":"00069068807"},{"Id":386393,"FormularyType":"OHP","DrugName":"TALZENNA CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535580400120","GenericName":"TALAZOPARIB TOSYLATE CAP 1 MG (BASE EQUIVALENT)","NDC":"00069075730"},{"Id":386394,"FormularyType":"OHP","DrugName":"XELJANZ TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065100320","GenericName":"TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT)","NDC":"00069100101"},{"Id":386395,"FormularyType":"OHP","DrugName":"XELJANZ TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065100330","GenericName":"TOFACITINIB CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00069100201"},{"Id":386396,"FormularyType":"OHP","DrugName":"BOSULIF CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531812000130","GenericName":"BOSUTINIB CAP 100 MG","NDC":"00069101415"},{"Id":386397,"FormularyType":"OHP","DrugName":"XELJANZ SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065102020","GenericName":"TOFACITINIB CITRATE ORAL SOLN 1 MG/ML (BASE EQUIVALENT)","NDC":"00069102901"},{"Id":386398,"FormularyType":"OHP","DrugName":"XELJANZ SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065102020","GenericName":"TOFACITINIB CITRATE ORAL SOLN 1 MG/ML (BASE EQUIVALENT)","NDC":"00069102902"},{"Id":386399,"FormularyType":"OHP","DrugName":"VIZIMPRO TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360019000330","GenericName":"DACOMITINIB TAB 30 MG","NDC":"00069119830"},{"Id":386400,"FormularyType":"OHP","DrugName":"RETACRIT INJ 2000UNIT","DosageForm":"SOLN - Solution","Strength":"2000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042010","GenericName":"EPOETIN ALFA-EPBX INJ 2000 UNIT/ML","NDC":"00069130501"},{"Id":386401,"FormularyType":"OHP","DrugName":"RETACRIT INJ 2000UNIT","DosageForm":"SOLN - Solution","Strength":"2000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042010","GenericName":"EPOETIN ALFA-EPBX INJ 2000 UNIT/ML","NDC":"00069130510"},{"Id":386402,"FormularyType":"OHP","DrugName":"RETACRIT INJ 3000UNIT","DosageForm":"SOLN - Solution","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042015","GenericName":"EPOETIN ALFA-EPBX INJ 3000 UNIT/ML","NDC":"00069130601"},{"Id":386403,"FormularyType":"OHP","DrugName":"RETACRIT INJ 3000UNIT","DosageForm":"SOLN - Solution","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042015","GenericName":"EPOETIN ALFA-EPBX INJ 3000 UNIT/ML","NDC":"00069130610"},{"Id":386404,"FormularyType":"OHP","DrugName":"RETACRIT INJ 4000UNIT","DosageForm":"SOLN - Solution","Strength":"4000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042020","GenericName":"EPOETIN ALFA-EPBX INJ 4000 UNIT/ML","NDC":"00069130701"},{"Id":386405,"FormularyType":"OHP","DrugName":"RETACRIT INJ 4000UNIT","DosageForm":"SOLN - Solution","Strength":"4000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042020","GenericName":"EPOETIN ALFA-EPBX INJ 4000 UNIT/ML","NDC":"00069130710"},{"Id":386406,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"00069130801"},{"Id":386407,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"00069130810"},{"Id":386408,"FormularyType":"OHP","DrugName":"RETACRIT INJ 40000UNT","DosageForm":"SOLN - Solution","Strength":"40000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042060","GenericName":"EPOETIN ALFA-EPBX INJ 40000 UNIT/ML","NDC":"00069130901"},{"Id":386409,"FormularyType":"OHP","DrugName":"RETACRIT INJ 40000UNT","DosageForm":"SOLN - Solution","Strength":"40000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042060","GenericName":"EPOETIN ALFA-EPBX INJ 40000 UNIT/ML","NDC":"00069130904"},{"Id":386410,"FormularyType":"OHP","DrugName":"RETACRIT INJ 20000UNI","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042050","GenericName":"EPOETIN ALFA-EPBX INJ 20000 UNIT/ML","NDC":"00069131101"},{"Id":386411,"FormularyType":"OHP","DrugName":"RETACRIT INJ 20000UNI","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042050","GenericName":"EPOETIN ALFA-EPBX INJ 20000 UNIT/ML","NDC":"00069131110"},{"Id":386412,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"00069131801"},{"Id":386413,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"00069131810"},{"Id":386414,"FormularyType":"OHP","DrugName":"DAURISMO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21370030300335","GenericName":"GLASDEGIB MALEATE TAB 100 MG (BASE EQUIVALENT)","NDC":"00069153130"},{"Id":386415,"FormularyType":"OHP","DrugName":"HYMPAVZI INJ 150MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"150","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIHEMOPHILIC PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8510505020D520","GenericName":"MARSTACIMAB-HNCQ SUBCUTANEOUS SOLN AUTO-INJ 150 MG/ML","NDC":"00069215101"},{"Id":386416,"FormularyType":"OHP","DrugName":"VIZIMPRO TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360019000340","GenericName":"DACOMITINIB TAB 45 MG","NDC":"00069229930"},{"Id":386417,"FormularyType":"OHP","DrugName":"ABRYSVO INJ 120MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"120","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100072202120","GenericName":"RSV PRE-FUSION F A&B VAC RECOMB FOR IM SOLN 120 MCG/0.5ML","NDC":"00069246501"},{"Id":386418,"FormularyType":"OHP","DrugName":"ABRYSVO INJ 120MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"120","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100072202120","GenericName":"RSV PRE-FUSION F A&B VAC RECOMB FOR IM SOLN 120 MCG/0.5ML","NDC":"00069246510"},{"Id":386419,"FormularyType":"OHP","DrugName":"ABRYSVO INJ 120MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"120","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100072202120","GenericName":"RSV PRE-FUSION F A&B VAC RECOMB FOR IM SOLN 120 MCG/0.5ML","NDC":"00069246519"},{"Id":386420,"FormularyType":"OHP","DrugName":"COMIRNATY 5- INJ 11/25-26","DosageForm":"SUSP - Suspension","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"7","AgeMinUnit":"Y","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"17100002401827","GenericName":"COVID-19 MRNA VAC TRIS-S 5-11Y-PFIZER IM SUSP 10 MCG/0.3ML","NDC":"00069250101"},{"Id":386421,"FormularyType":"OHP","DrugName":"COMIRNATY 5- INJ 11/25-26","DosageForm":"SUSP - Suspension","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"7","AgeMinUnit":"Y","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"17100002401827","GenericName":"COVID-19 MRNA VAC TRIS-S 5-11Y-PFIZER IM SUSP 10 MCG/0.3ML","NDC":"00069250110"},{"Id":386422,"FormularyType":"OHP","DrugName":"COMIRNATY INJ 30/.3ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"30","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E620","GenericName":"COVID-19 MRNA VAC TRIS-PFIZER IM SUSP PREF SYR 30 MCG/0.3ML","NDC":"00069252801"},{"Id":386423,"FormularyType":"OHP","DrugName":"COMIRNATY INJ 30/.3ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"30","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E620","GenericName":"COVID-19 MRNA VAC TRIS-PFIZER IM SUSP PREF SYR 30 MCG/0.3ML","NDC":"00069252810"},{"Id":386424,"FormularyType":"OHP","DrugName":"PAXLOVID TAB 300-100","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIVIRAL COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1299000255B720","GenericName":"NIRMATRELVIR TAB 20 X 150 MG & RITONAVIR TAB 10 X 100 MG PAK","NDC":"00069504506"},{"Id":386425,"FormularyType":"OHP","DrugName":"PAXLOVID TAB 300-100","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIVIRAL COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1299000255B720","GenericName":"NIRMATRELVIR TAB 20 X 150 MG & RITONAVIR TAB 10 X 100 MG PAK","NDC":"00069504530"},{"Id":386426,"FormularyType":"OHP","DrugName":"PAXLOVID TAB 150-100","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIVIRAL COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1299000255B710","GenericName":"NIRMATRELVIR TAB 10 X 150 MG & RITONAVIR TAB 10 X 100 MG PAK","NDC":"00069543402"},{"Id":386427,"FormularyType":"OHP","DrugName":"PAXLOVID TAB 150-100","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIVIRAL COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1299000255B710","GenericName":"NIRMATRELVIR TAB 10 X 150 MG & RITONAVIR TAB 10 X 100 MG PAK","NDC":"00069543420"},{"Id":386428,"FormularyType":"OHP","DrugName":"LEUCOVORIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00069588624"},{"Id":386429,"FormularyType":"OHP","DrugName":"LEUCOVORIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00069588699"},{"Id":386430,"FormularyType":"OHP","DrugName":"XALKORI CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530517000125","GenericName":"CRIZOTINIB CAP 250 MG","NDC":"00069814020"},{"Id":386431,"FormularyType":"OHP","DrugName":"XALKORI CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530517000120","GenericName":"CRIZOTINIB CAP 200 MG","NDC":"00069814120"},{"Id":386432,"FormularyType":"OHP","DrugName":"VYNDAMAX CAP 61MG","DosageForm":"CAPS - Capsule","Strength":"61","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"TRANSTHYRETIN STABILIZERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40550080000120","GenericName":"TAFAMIDIS CAP 61 MG","NDC":"00069873001"},{"Id":386433,"FormularyType":"OHP","DrugName":"VYNDAMAX CAP 61MG","DosageForm":"CAPS - Capsule","Strength":"61","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"TRANSTHYRETIN STABILIZERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40550080000120","GenericName":"TAFAMIDIS CAP 61 MG","NDC":"00069873030"},{"Id":386434,"FormularyType":"OHP","DrugName":"DILANTIN CHW 50MG","DosageForm":"CHEW - Tablet Chewable","Strength":"50","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030000505","GenericName":"PHENYTOIN CHEW TAB 50 MG","NDC":"00071000724"},{"Id":386435,"FormularyType":"OHP","DrugName":"DILANTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"00071036932"},{"Id":386436,"FormularyType":"OHP","DrugName":"DILANTIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200105","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 30 MG","NDC":"00071374066"},{"Id":386437,"FormularyType":"OHP","DrugName":"ORILISSA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GNRH/LHRH ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30090030100320","GenericName":"ELAGOLIX SODIUM TAB 150 MG (BASE EQUIV)","NDC":"00074003828"},{"Id":386438,"FormularyType":"OHP","DrugName":"ORILISSA TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GNRH/LHRH ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30090030100330","GenericName":"ELAGOLIX SODIUM TAB 200 MG (BASE EQUIV)","NDC":"00074003956"},{"Id":386439,"FormularyType":"OHP","DrugName":"REHYDRALYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074016201"},{"Id":386440,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FREEZE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074024501"},{"Id":386441,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000320","GenericName":"VENETOCLAX TAB 10 MG","NDC":"00074056111"},{"Id":386442,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000320","GenericName":"VENETOCLAX TAB 10 MG","NDC":"00074056114"},{"Id":386443,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000340","GenericName":"VENETOCLAX TAB 50 MG","NDC":"00074056607"},{"Id":386444,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000340","GenericName":"VENETOCLAX TAB 50 MG","NDC":"00074056611"},{"Id":386445,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000360","GenericName":"VENETOCLAX TAB 100 MG","NDC":"00074057611"},{"Id":386446,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000360","GenericName":"VENETOCLAX TAB 100 MG","NDC":"00074057622"},{"Id":386447,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21470080000360","GenericName":"VENETOCLAX TAB 100 MG","NDC":"00074057630"},{"Id":386448,"FormularyType":"OHP","DrugName":"VENCLEXTA TAB START PK","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - BCL-2 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2147008000B720","GenericName":"VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG","NDC":"00074057928"},{"Id":386449,"FormularyType":"OHP","DrugName":"RINVOQ TAB 45MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"45","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603072007540","GenericName":"UPADACITINIB TAB ER 24HR 45 MG","NDC":"00074104328"},{"Id":386450,"FormularyType":"OHP","DrugName":"SKYRIZI INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057070E540","GenericName":"RISANKIZUMAB-RZAA SOLN PREFILLED SYRINGE 150 MG/ML","NDC":"00074105001"},{"Id":386451,"FormularyType":"OHP","DrugName":"SKYRIZI INJ 180/1.2","DosageForm":"SOCT - Soln Cartridge","Strength":"180","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250406070E210","GenericName":"RISANKIZUMAB-RZAA SUBCUTANEOUS SOLN CARTRIDGE 180 MG/1.2ML","NDC":"00074106501"},{"Id":386452,"FormularyType":"OHP","DrugName":"SKYRIZI INJ 180/1.2","DosageForm":"SOCT - Soln Cartridge","Strength":"180","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250406070E210","GenericName":"RISANKIZUMAB-RZAA SUBCUTANEOUS SOLN CARTRIDGE 180 MG/1.2ML","NDC":"00074106601"},{"Id":386453,"FormularyType":"OHP","DrugName":"SKYRIZI INJ 360/2.4","DosageForm":"SOCT - Soln Cartridge","Strength":"360","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250406070E220","GenericName":"RISANKIZUMAB-RZAA SUBCUTANEOUS SOLN CARTRIDGE 360 MG/2.4ML","NDC":"00074106901"},{"Id":386454,"FormularyType":"OHP","DrugName":"SKYRIZI INJ 360/2.4","DosageForm":"SOCT - Soln Cartridge","Strength":"360","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5250406070E220","GenericName":"RISANKIZUMAB-RZAA SUBCUTANEOUS SOLN CARTRIDGE 360 MG/2.4ML","NDC":"00074107001"},{"Id":386455,"FormularyType":"OHP","DrugName":"SKYRIZI PEN INJ 150MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"150","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057070D520","GenericName":"RISANKIZUMAB-RZAA SOLN AUTO-INJECTOR 150 MG/ML","NDC":"00074210001"},{"Id":386456,"FormularyType":"OHP","DrugName":"LUPR DEP-PED INJ 7.5MG","DosageForm":"KIT - Kit","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30080050106420","GenericName":"LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 7.5 MG","NDC":"00074210803"},{"Id":386457,"FormularyType":"OHP","DrugName":"LUPR DEP-PED INJ 11.25MG","DosageForm":"KIT - Kit","Strength":"11.25","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30080050106430","GenericName":"LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 11.25 MG","NDC":"00074228203"},{"Id":386458,"FormularyType":"OHP","DrugName":"RINVOQ TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603072007520","GenericName":"UPADACITINIB TAB ER 24HR 15 MG","NDC":"00074230630"},{"Id":386459,"FormularyType":"OHP","DrugName":"RINVOQ TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603072007520","GenericName":"UPADACITINIB TAB ER 24HR 15 MG","NDC":"00074230670"},{"Id":386460,"FormularyType":"OHP","DrugName":"RINVOQ TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603072007530","GenericName":"UPADACITINIB TAB ER 24HR 30 MG","NDC":"00074231030"},{"Id":386461,"FormularyType":"OHP","DrugName":"RINVOQ LQ SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603072002020","GenericName":"UPADACITINIB ORAL SOLN 1 MG/ML","NDC":"00074232001"},{"Id":386462,"FormularyType":"OHP","DrugName":"LUPR DEP-PED INJ 15MG","DosageForm":"KIT - Kit","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30080050106440","GenericName":"LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 15 MG","NDC":"00074244003"},{"Id":386463,"FormularyType":"OHP","DrugName":"MAVYRET TAB 100-40MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12359902350320","GenericName":"GLECAPREVIR-PIBRENTASVIR TAB 100-40 MG","NDC":"00074262504"},{"Id":386464,"FormularyType":"OHP","DrugName":"MAVYRET TAB 100-40MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12359902350320","GenericName":"GLECAPREVIR-PIBRENTASVIR TAB 100-40 MG","NDC":"00074262528"},{"Id":386465,"FormularyType":"OHP","DrugName":"MAVYRET TAB 100-40MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12359902350320","GenericName":"GLECAPREVIR-PIBRENTASVIR TAB 100-40 MG","NDC":"00074262584"},{"Id":386466,"FormularyType":"OHP","DrugName":"GENGRAF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"00074310832"},{"Id":386467,"FormularyType":"OHP","DrugName":"GENGRAF CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"00074310932"},{"Id":386468,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 22.5MG","DosageForm":"KIT - Kit","Strength":"22.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010156430","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 22.5 MG","NDC":"00074334603"},{"Id":386469,"FormularyType":"OHP","DrugName":"NORVIR POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104560003020","GenericName":"RITONAVIR POWDER PACKET 100 MG","NDC":"00074339930"},{"Id":386470,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 45MG","DosageForm":"KIT - Kit","Strength":"45","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010256450","GenericName":"LEUPROLIDE ACETATE (6 MONTH) FOR INJ KIT 45 MG","NDC":"00074347303"},{"Id":386471,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 45MG","DosageForm":"KIT - Kit","Strength":"45","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30080050256460","GenericName":"LEUPROLIDE ACET (6 MONTH) FOR IM INJ PEDIATRIC KIT 45 MG","NDC":"00074357501"},{"Id":386472,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 3.75MG","DosageForm":"KIT - Kit","Strength":"3.75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106405","GenericName":"LEUPROLIDE ACETATE FOR INJ KIT 3.75 MG","NDC":"00074364103"},{"Id":386473,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 7.5MG","DosageForm":"KIT - Kit","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106410","GenericName":"LEUPROLIDE ACETATE FOR INJ KIT 7.5 MG","NDC":"00074364203"},{"Id":386474,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 11.25MG","DosageForm":"KIT - Kit","Strength":"11.25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010156420","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 11.25 MG","NDC":"00074366303"},{"Id":386475,"FormularyType":"OHP","DrugName":"LUPRON DEPOT INJ 30MG","DosageForm":"KIT - Kit","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010206430","GenericName":"LEUPROLIDE ACETATE (4 MONTH) FOR INJ KIT 30 MG","NDC":"00074368303"},{"Id":386476,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"00074372719"},{"Id":386477,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"00074372790"},{"Id":386478,"FormularyType":"OHP","DrugName":"LUPR DEP-PED INJ 11.25MG","DosageForm":"KIT - Kit","Strength":"11.25","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30080050156420","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 11.25 MG","NDC":"00074377903"},{"Id":386479,"FormularyType":"OHP","DrugName":"KALETRA SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902552020","GenericName":"LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML)","NDC":"00074395646"},{"Id":386480,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00074434119"},{"Id":386481,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00074434190"},{"Id":386482,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00074455211"},{"Id":386483,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00074455219"},{"Id":386484,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00074455290"},{"Id":386485,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BUBL GUM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074517530"},{"Id":386486,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00074518211"},{"Id":386487,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00074518219"},{"Id":386488,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00074518290"},{"Id":386489,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074549820"},{"Id":386490,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074647008"},{"Id":386491,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074647032"},{"Id":386492,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00074647132"},{"Id":386493,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00074659419"},{"Id":386494,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00074659490"},{"Id":386495,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00074662411"},{"Id":386496,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00074662419"},{"Id":386497,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00074662490"},{"Id":386498,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00074706811"},{"Id":386499,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00074706819"},{"Id":386500,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00074706890"},{"Id":386501,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00074706911"},{"Id":386502,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00074706919"},{"Id":386503,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00074706990"},{"Id":386504,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00074707019"},{"Id":386505,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00074707090"},{"Id":386506,"FormularyType":"OHP","DrugName":"QULIPTA TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701010000330","GenericName":"ATOGEPANT TAB 60 MG","NDC":"00074709430"},{"Id":386507,"FormularyType":"OHP","DrugName":"QULIPTA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701010000310","GenericName":"ATOGEPANT TAB 10 MG","NDC":"00074709530"},{"Id":386508,"FormularyType":"OHP","DrugName":"QULIPTA TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67701010000320","GenericName":"ATOGEPANT TAB 30 MG","NDC":"00074709630"},{"Id":386509,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00074714811"},{"Id":386510,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00074714819"},{"Id":386511,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00074714890"},{"Id":386512,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"00074714919"},{"Id":386513,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"00074714990"},{"Id":386514,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00074929619"},{"Id":386515,"FormularyType":"OHP","DrugName":"SYNTHROID TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00074929690"},{"Id":386516,"FormularyType":"OHP","DrugName":"LUPR DEP-PED INJ 3M 30MG","DosageForm":"KIT - Kit","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30080050156440","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 30 MG","NDC":"00074969403"},{"Id":386517,"FormularyType":"OHP","DrugName":"TRILEPTAL SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"00078035752"},{"Id":386518,"FormularyType":"OHP","DrugName":"COARTEM TAB 20-120MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIAL COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13990002030320","GenericName":"ARTEMETHER-LUMEFANTRINE TAB 20-120 MG","NDC":"00078056845"},{"Id":386519,"FormularyType":"OHP","DrugName":"COSENTYX PEN INJ 300DOSE","DosageForm":"SOAJ - Soln Auto-inj","Strength":"150","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057500D530","GenericName":"SECUKINUMAB SUBCUTANEOUS AUTO-INJ 150 MG/ML (300 MG DOSE)","NDC":"00078063941"},{"Id":386520,"FormularyType":"OHP","DrugName":"COSENTYX INJ 300DOSE","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057500E530","GenericName":"SECUKINUMAB SUBCUTANEOUS PREF SYR 150 MG/ML (300 MG DOSE)","NDC":"00078063998"},{"Id":386521,"FormularyType":"OHP","DrugName":"TAFINLAR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532025100130","GenericName":"DABRAFENIB MESYLATE CAP 75 MG (BASE EQUIVALENT)","NDC":"00078068166"},{"Id":386522,"FormularyType":"OHP","DrugName":"TAFINLAR CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532025100120","GenericName":"DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT)","NDC":"00078068266"},{"Id":386523,"FormularyType":"OHP","DrugName":"ZYKADIA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530514000330","GenericName":"CERITINIB TAB 150 MG","NDC":"00078069484"},{"Id":386524,"FormularyType":"OHP","DrugName":"RYDAPT CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533030000130","GenericName":"MIDOSTAURIN CAP 25 MG","NDC":"00078069802"},{"Id":386525,"FormularyType":"OHP","DrugName":"RYDAPT CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533030000130","GenericName":"MIDOSTAURIN CAP 25 MG","NDC":"00078069819"},{"Id":386526,"FormularyType":"OHP","DrugName":"RYDAPT CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533030000130","GenericName":"MIDOSTAURIN CAP 25 MG","NDC":"00078069851"},{"Id":386527,"FormularyType":"OHP","DrugName":"RYDAPT CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533030000130","GenericName":"MIDOSTAURIN CAP 25 MG","NDC":"00078069899"},{"Id":386528,"FormularyType":"OHP","DrugName":"PIQRAY 200MG TAB DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153801000B720","GenericName":"ALPELISIB TAB THERAPY PACK 200 MG DAILY DOSE","NDC":"00078070151"},{"Id":386529,"FormularyType":"OHP","DrugName":"PIQRAY 200MG TAB DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153801000B720","GenericName":"ALPELISIB TAB THERAPY PACK 200 MG DAILY DOSE","NDC":"00078070184"},{"Id":386530,"FormularyType":"OHP","DrugName":"PIQRAY 300MG TAB DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153801000B730","GenericName":"ALPELISIB TAB PACK 300 MG DAILY DOSE (2X150 MG TAB)","NDC":"00078070802"},{"Id":386531,"FormularyType":"OHP","DrugName":"PIQRAY 300MG TAB DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153801000B730","GenericName":"ALPELISIB TAB PACK 300 MG DAILY DOSE (2X150 MG TAB)","NDC":"00078070851"},{"Id":386532,"FormularyType":"OHP","DrugName":"TABRECTA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533716200320","GenericName":"CAPMATINIB HCL TAB 150 MG","NDC":"00078070956"},{"Id":386533,"FormularyType":"OHP","DrugName":"PIQRAY 250MG TAB DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153801000B725","GenericName":"ALPELISIB TAB PACK 250 MG DAILY DOSE (200 MG & 50 MG TABS)","NDC":"00078071502"},{"Id":386534,"FormularyType":"OHP","DrugName":"PIQRAY 250MG TAB DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153801000B725","GenericName":"ALPELISIB TAB PACK 250 MG DAILY DOSE (200 MG & 50 MG TABS)","NDC":"00078071561"},{"Id":386535,"FormularyType":"OHP","DrugName":"TABRECTA TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533716200330","GenericName":"CAPMATINIB HCL TAB 200 MG","NDC":"00078071656"},{"Id":386536,"FormularyType":"OHP","DrugName":"KISQALI TAB 200DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153107050B720","GenericName":"RIBOCICLIB SUCCINATE TAB PACK 200 MG DAILY DOSE","NDC":"00078086001"},{"Id":386537,"FormularyType":"OHP","DrugName":"KISQALI TAB 400DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153107050B740","GenericName":"RIBOCICLIB SUCCINATE TAB PACK 400 MG DAILY DOSE (200 MG TAB)","NDC":"00078086714"},{"Id":386538,"FormularyType":"OHP","DrugName":"KISQALI TAB 400DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153107050B740","GenericName":"RIBOCICLIB SUCCINATE TAB PACK 400 MG DAILY DOSE (200 MG TAB)","NDC":"00078086742"},{"Id":386539,"FormularyType":"OHP","DrugName":"KISQALI TAB 600DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153107050B760","GenericName":"RIBOCICLIB SUCCINATE TAB PACK 600 MG DAILY DOSE (200 MG TAB)","NDC":"00078087421"},{"Id":386540,"FormularyType":"OHP","DrugName":"KISQALI TAB 600DOSE","DosageForm":"TBPK - Tab Ther Pack","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153107050B760","GenericName":"RIBOCICLIB SUCCINATE TAB PACK 600 MG DAILY DOSE (200 MG TAB)","NDC":"00078087463"},{"Id":386541,"FormularyType":"OHP","DrugName":"TOBRADEX OIN 0.3-0.1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902804220","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH OINT 0.3-0.1%","NDC":"00078087601"},{"Id":386542,"FormularyType":"OHP","DrugName":"MAYZENT PAK STARTER","DosageForm":"TBPK - Tab Ther Pack","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240707020B720","GenericName":"SIPONIMOD FUMARATE TAB 0.25 MG (12) STARTER PACK","NDC":"00078097912"},{"Id":386543,"FormularyType":"OHP","DrugName":"MAYZENT TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407070200320","GenericName":"SIPONIMOD FUMARATE TAB 0.25 MG (BASE EQUIV)","NDC":"00078097950"},{"Id":386544,"FormularyType":"OHP","DrugName":"MAYZENT PAK STARTER","DosageForm":"TBPK - Tab Ther Pack","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240707020B710","GenericName":"SIPONIMOD FUMARATE TAB 0.25 MG (7) STARTER PACK","NDC":"00078097989"},{"Id":386545,"FormularyType":"OHP","DrugName":"MAYZENT TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407070200340","GenericName":"SIPONIMOD FUMARATE TAB 2 MG (BASE EQUIV)","NDC":"00078098615"},{"Id":386546,"FormularyType":"OHP","DrugName":"MAYZENT TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407070200340","GenericName":"SIPONIMOD FUMARATE TAB 2 MG (BASE EQUIV)","NDC":"00078098645"},{"Id":386547,"FormularyType":"OHP","DrugName":"MAYZENT TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407070200330","GenericName":"SIPONIMOD FUMARATE TAB 1 MG (BASE EQUIV)","NDC":"00078101415"},{"Id":386548,"FormularyType":"OHP","DrugName":"VIJOICE TAB 50MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9948601000B720","GenericName":"ALPELISIB (PROS) TAB THERAPY PACK 50 MG DAILY DOSE","NDC":"00078102151"},{"Id":386549,"FormularyType":"OHP","DrugName":"VIJOICE TAB 50MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9948601000B720","GenericName":"ALPELISIB (PROS) TAB THERAPY PACK 50 MG DAILY DOSE","NDC":"00078102184"},{"Id":386550,"FormularyType":"OHP","DrugName":"VIJOICE TAB 125MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"125","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9948601000B730","GenericName":"ALPELISIB (PROS) TAB THERAPY PACK 125 MG DAILY DOSE","NDC":"00078102851"},{"Id":386551,"FormularyType":"OHP","DrugName":"VIJOICE TAB 125MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"125","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9948601000B730","GenericName":"ALPELISIB (PROS) TAB THERAPY PACK 125 MG DAILY DOSE","NDC":"00078102884"},{"Id":386552,"FormularyType":"OHP","DrugName":"VIJOICE TAB 250MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9948601000B740","GenericName":"ALPELISIB (PROS) PAK 250 MG DAILY DOSE (200 MG & 50 MG TABS)","NDC":"00078103502"},{"Id":386553,"FormularyType":"OHP","DrugName":"VIJOICE TAB 250MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9948601000B740","GenericName":"ALPELISIB (PROS) PAK 250 MG DAILY DOSE (200 MG & 50 MG TABS)","NDC":"00078103561"},{"Id":386554,"FormularyType":"OHP","DrugName":"COSENTYX INJ 75MG/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"75","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057500E510","GenericName":"SECUKINUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML","NDC":"00078105697"},{"Id":386555,"FormularyType":"OHP","DrugName":"COSENTYX UNO INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057500D550","GenericName":"SECUKINUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"00078107068"},{"Id":386556,"FormularyType":"OHP","DrugName":"COSENTYX UNO INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025057500D550","GenericName":"SECUKINUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"00078107096"},{"Id":386557,"FormularyType":"OHP","DrugName":"SCEMBLIX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531806100320","GenericName":"ASCIMINIB HCL TAB 20 MG","NDC":"00078109120"},{"Id":386558,"FormularyType":"OHP","DrugName":"SCEMBLIX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531806100340","GenericName":"ASCIMINIB HCL TAB 40 MG","NDC":"00078109820"},{"Id":386559,"FormularyType":"OHP","DrugName":"MEKINIST TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533570100310","GenericName":"TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT)","NDC":"00078110515"},{"Id":386560,"FormularyType":"OHP","DrugName":"MEKINIST TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533570100330","GenericName":"TRAMETINIB DIMETHYL SULFOXIDE TAB 2 MG (BASE EQUIVALENT)","NDC":"00078111215"},{"Id":386561,"FormularyType":"OHP","DrugName":"TAFINLAR TAB 10MG","DosageForm":"TBSO - Tablet Soluble","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532025107320","GenericName":"DABRAFENIB MESYLATE TAB FOR ORAL SUSP 10 MG (BASE EQUIV)","NDC":"00078115421"},{"Id":386562,"FormularyType":"OHP","DrugName":"MEKINIST SOL 0.05/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.05","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533570102120","GenericName":"TRAMETINIB DIMETHYL SULFOXIDE FOR SOLN 0.05 MG/ML (BASE EQ)","NDC":"00078116147"},{"Id":386563,"FormularyType":"OHP","DrugName":"VIJOICE GRA 50MG","DosageForm":"PACK - Packet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99486010003020","GenericName":"ALPELISIB (PROS) ORAL GRANULES PACKET 50 MG","NDC":"00078117519"},{"Id":386564,"FormularyType":"OHP","DrugName":"VIJOICE GRA 50MG","DosageForm":"PACK - Packet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99486010003020","GenericName":"ALPELISIB (PROS) ORAL GRANULES PACKET 50 MG","NDC":"00078117551"},{"Id":386565,"FormularyType":"OHP","DrugName":"FABHALTA CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85807535200130","GenericName":"IPTACOPAN HCL CAP 200 MG","NDC":"00078118920"},{"Id":386566,"FormularyType":"OHP","DrugName":"SCEMBLIX TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531806100380","GenericName":"ASCIMINIB HCL TAB 100 MG","NDC":"00078119620"},{"Id":386567,"FormularyType":"OHP","DrugName":"VANRAFIA TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"IGA NEPHROPATHY (IGAN) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56482507200320","GenericName":"ATRASENTAN HCL TAB 0.75 MG","NDC":"00078142015"},{"Id":386568,"FormularyType":"OHP","DrugName":"NEOSPORIN+PN OIN RELF MAX","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"00081074687"},{"Id":386569,"FormularyType":"OHP","DrugName":"NEOSPORIN+PN OIN RELF MAX","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"00081074688"},{"Id":386570,"FormularyType":"OHP","DrugName":"NITRO-DUR DIS 0.8MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.8","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008560","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.8 MG/HR","NDC":"00085081901"},{"Id":386571,"FormularyType":"OHP","DrugName":"NITRO-DUR DIS 0.3MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008530","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.3 MG/HR","NDC":"00085331501"},{"Id":386572,"FormularyType":"OHP","DrugName":"INSPIREASE MIS DD SYST","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"00085460202"},{"Id":386573,"FormularyType":"OHP","DrugName":"POLY-VI-SOL SOL 50MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"00087040203"},{"Id":386574,"FormularyType":"OHP","DrugName":"POLY-VI-SOL SOL 50MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"00087040265"},{"Id":386575,"FormularyType":"OHP","DrugName":"TRI-VI-SOL SOL A/C/D","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002019","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 250 MCG-10 MCG-50MG/ML***","NDC":"00087040303"},{"Id":386576,"FormularyType":"OHP","DrugName":"TRI-VI-SOL SOL A/C/D","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002019","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 250 MCG-10 MCG-50MG/ML***","NDC":"00087040365"},{"Id":386577,"FormularyType":"OHP","DrugName":"POLY-VI-SOL SOL IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"00087040501"},{"Id":386578,"FormularyType":"OHP","DrugName":"POLY-VI-SOL SOL IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"00087040506"},{"Id":386579,"FormularyType":"OHP","DrugName":"3232A INFANT POW FORMULA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087042521"},{"Id":386580,"FormularyType":"OHP","DrugName":"3232A INFANT POW FORMULA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087042541"},{"Id":386581,"FormularyType":"OHP","DrugName":"FER-IN-SOL DRO 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"00087074002"},{"Id":386582,"FormularyType":"OHP","DrugName":"FER-IN-SOL DRO 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"00087074026"},{"Id":386583,"FormularyType":"OHP","DrugName":"D-VI-SOL LIQ 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"00087086604"},{"Id":386584,"FormularyType":"OHP","DrugName":"D-VI-SOL LIQ 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"00087086644"},{"Id":386585,"FormularyType":"OHP","DrugName":"PHENYL-FREE POW 2","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510003"},{"Id":386586,"FormularyType":"OHP","DrugName":"PHENYL-FREE POW 2HP","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510010"},{"Id":386587,"FormularyType":"OHP","DrugName":"BCAD 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510015"},{"Id":386588,"FormularyType":"OHP","DrugName":"PFD 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510018"},{"Id":386589,"FormularyType":"OHP","DrugName":"OA 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510022"},{"Id":386590,"FormularyType":"OHP","DrugName":"TYROS 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510024"},{"Id":386591,"FormularyType":"OHP","DrugName":"HCY 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510027"},{"Id":386592,"FormularyType":"OHP","DrugName":"WND 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510029"},{"Id":386593,"FormularyType":"OHP","DrugName":"PHENYL-FREE POW 2","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510108"},{"Id":386594,"FormularyType":"OHP","DrugName":"PHENYL-FREE POW 2HP","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510109"},{"Id":386595,"FormularyType":"OHP","DrugName":"BCAD 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510110"},{"Id":386596,"FormularyType":"OHP","DrugName":"PFD 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510111"},{"Id":386597,"FormularyType":"OHP","DrugName":"OA 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510112"},{"Id":386598,"FormularyType":"OHP","DrugName":"TYROS 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510113"},{"Id":386599,"FormularyType":"OHP","DrugName":"HCY 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510114"},{"Id":386600,"FormularyType":"OHP","DrugName":"WND 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510115"},{"Id":386601,"FormularyType":"OHP","DrugName":"PFD TODDLER POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510178"},{"Id":386602,"FormularyType":"OHP","DrugName":"PFD TODDLER POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510179"},{"Id":386603,"FormularyType":"OHP","DrugName":"BCAD 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510184"},{"Id":386604,"FormularyType":"OHP","DrugName":"BCAD 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510185"},{"Id":386605,"FormularyType":"OHP","DrugName":"GA POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510188"},{"Id":386606,"FormularyType":"OHP","DrugName":"GA POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510189"},{"Id":386607,"FormularyType":"OHP","DrugName":"TYROS 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510191"},{"Id":386608,"FormularyType":"OHP","DrugName":"TYROS 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510192"},{"Id":386609,"FormularyType":"OHP","DrugName":"LMD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510196"},{"Id":386610,"FormularyType":"OHP","DrugName":"LMD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510197"},{"Id":386611,"FormularyType":"OHP","DrugName":"OA 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510199"},{"Id":386612,"FormularyType":"OHP","DrugName":"OA 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510200"},{"Id":386613,"FormularyType":"OHP","DrugName":"HCY 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510202"},{"Id":386614,"FormularyType":"OHP","DrugName":"HCY 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510203"},{"Id":386615,"FormularyType":"OHP","DrugName":"WND 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510205"},{"Id":386616,"FormularyType":"OHP","DrugName":"WND 1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087510206"},{"Id":386617,"FormularyType":"OHP","DrugName":"ENFAMIL MIS EXPECTA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006319","GenericName":"*PRENATAL W/FE FUM-FA TAB 28-0.8 MG & DHA CAP 200 MG PACK*","NDC":"00087510586"},{"Id":386618,"FormularyType":"OHP","DrugName":"ENFAMIL SOL ENFALYTE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00087511503"},{"Id":386619,"FormularyType":"OHP","DrugName":"PORTAGEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087511728"},{"Id":386620,"FormularyType":"OHP","DrugName":"PORTAGEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00087511729"},{"Id":386621,"FormularyType":"OHP","DrugName":"ENFAMIL SOL ENFALYTE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00087511834"},{"Id":386622,"FormularyType":"OHP","DrugName":"ENFAMIL SOL ENFALYTE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00087512158"},{"Id":386623,"FormularyType":"OHP","DrugName":"ENFAMIL SOL ENFALYTE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00087512159"},{"Id":386624,"FormularyType":"OHP","DrugName":"POLY-VI-SOL DRO IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"00087512746"},{"Id":386625,"FormularyType":"OHP","DrugName":"PRIFTIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000085000320","GenericName":"RIFAPENTINE TAB 150 MG","NDC":"00088210201"},{"Id":386626,"FormularyType":"OHP","DrugName":"PRIFTIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000085000320","GenericName":"RIFAPENTINE TAB 150 MG","NDC":"00088210224"},{"Id":386627,"FormularyType":"OHP","DrugName":"LANTUS SOLOS INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400300D220","GenericName":"INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00088221901"},{"Id":386628,"FormularyType":"OHP","DrugName":"LANTUS SOLOS INJ 100/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400300D220","GenericName":"INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00088221905"},{"Id":386629,"FormularyType":"OHP","DrugName":"LANTUS INJ 100/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104003002020","GenericName":"INSULIN GLARGINE INJ 100 UNIT/ML","NDC":"00088222033"},{"Id":386630,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"00093001006"},{"Id":386631,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"00093001805"},{"Id":386632,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"00093001806"},{"Id":386633,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"00093005101"},{"Id":386634,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"00093005105"},{"Id":386635,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"00093013501"},{"Id":386636,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"00093013505"},{"Id":386637,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"00093031101"},{"Id":386638,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"00093031105"},{"Id":386639,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"00093031801"},{"Id":386640,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"00093031805"},{"Id":386641,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"00093031901"},{"Id":386642,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"00093031905"},{"Id":386643,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"00093032001"},{"Id":386644,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100320","GenericName":"DILTIAZEM HCL TAB 120 MG","NDC":"00093032101"},{"Id":386645,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"00093057606"},{"Id":386646,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"00093057610"},{"Id":386647,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"00093075201"},{"Id":386648,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"00093075210"},{"Id":386649,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"00093075301"},{"Id":386650,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"00093075305"},{"Id":386651,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"00093078701"},{"Id":386652,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"00093078710"},{"Id":386653,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"00093083201"},{"Id":386654,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"00093083205"},{"Id":386655,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"00093092606"},{"Id":386656,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"00093092610"},{"Id":386657,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"00093092806"},{"Id":386658,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"00093092810"},{"Id":386659,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"00093094801"},{"Id":386660,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"00093094805"},{"Id":386661,"FormularyType":"OHP","DrugName":"NYSTATIN TAB 500000","DosageForm":"TABS - Tablet","Strength":"500000","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000060000305","GenericName":"NYSTATIN TAB 500000 UNIT","NDC":"00093098301"},{"Id":386662,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"00093101042"},{"Id":386663,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"00093106001"},{"Id":386664,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"00093106101"},{"Id":386665,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100320","GenericName":"SOTALOL HCL TAB 160 MG","NDC":"00093106201"},{"Id":386666,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100330","GenericName":"SOTALOL HCL TAB 240 MG","NDC":"00093106301"},{"Id":386667,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"00093107701"},{"Id":386668,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"00093107853"},{"Id":386669,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000110","GenericName":"ACITRETIN CAP 10 MG","NDC":"00093113556"},{"Id":386670,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000125","GenericName":"ACITRETIN CAP 25 MG","NDC":"00093113656"},{"Id":386671,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 17.5MG","DosageForm":"CAPS - Capsule","Strength":"17.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000115","GenericName":"ACITRETIN CAP 17.5 MG","NDC":"00093113856"},{"Id":386672,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"00093117201"},{"Id":386673,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"00093117210"},{"Id":386674,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"00093117401"},{"Id":386675,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"00093117410"},{"Id":386676,"FormularyType":"OHP","DrugName":"NEOMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000040100305","GenericName":"NEOMYCIN SULFATE TAB 500 MG","NDC":"00093117701"},{"Id":386677,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"00093171201"},{"Id":386678,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"00093171210"},{"Id":386679,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"00093171301"},{"Id":386680,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"00093171310"},{"Id":386681,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"00093171401"},{"Id":386682,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"00093171410"},{"Id":386683,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"00093171501"},{"Id":386684,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"00093171601"},{"Id":386685,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"00093171610"},{"Id":386686,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"00093171801"},{"Id":386687,"FormularyType":"OHP","DrugName":"WARFARIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"00093172001"},{"Id":386688,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"00093172101"},{"Id":386689,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"00093172110"},{"Id":386690,"FormularyType":"OHP","DrugName":"WARFARIN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"00093172301"},{"Id":386691,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"00093202623"},{"Id":386692,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"00093202631"},{"Id":386693,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"00093202694"},{"Id":386694,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"00093202723"},{"Id":386695,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000330","GenericName":"CILOSTAZOL TAB 100 MG","NDC":"00093206406"},{"Id":386696,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000330","GenericName":"CILOSTAZOL TAB 100 MG","NDC":"00093206450"},{"Id":386697,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000320","GenericName":"CILOSTAZOL TAB 50 MG","NDC":"00093206506"},{"Id":386698,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"00093206701"},{"Id":386699,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"00093206801"},{"Id":386700,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"00093206901"},{"Id":386701,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"00093207001"},{"Id":386702,"FormularyType":"OHP","DrugName":"TRI-LO- TAB SPRINTEC","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"00093214028"},{"Id":386703,"FormularyType":"OHP","DrugName":"TRI-LO- TAB SPRINTEC","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"00093214062"},{"Id":386704,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"00093217801"},{"Id":386705,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"00093217901"},{"Id":386706,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"00093218001"},{"Id":386707,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"00093220301"},{"Id":386708,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"00093220305"},{"Id":386709,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"00093220310"},{"Id":386710,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"00093220401"},{"Id":386711,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"00093220405"},{"Id":386712,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"00093221001"},{"Id":386713,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"00093221005"},{"Id":386714,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"00093221098"},{"Id":386715,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100303","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 500 MG","NDC":"00093226301"},{"Id":386716,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"00093226401"},{"Id":386717,"FormularyType":"OHP","DrugName":"AMOXICILLIN CHW 250MG","DosageForm":"CHEW - Tablet Chewable","Strength":"250","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100510","GenericName":"AMOXICILLIN (TRIHYDRATE) CHEW TAB 250 MG","NDC":"00093226801"},{"Id":386718,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"00093227434"},{"Id":386719,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"00093227534"},{"Id":386720,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00093227773"},{"Id":386721,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00093227973"},{"Id":386722,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"00093240101"},{"Id":386723,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"00093306619"},{"Id":386724,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"00093306634"},{"Id":386725,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"00093306693"},{"Id":386726,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"00093309819"},{"Id":386727,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"00093309829"},{"Id":386728,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"00093309844"},{"Id":386729,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100305","GenericName":"RISEDRONATE SODIUM TAB 5 MG","NDC":"00093309956"},{"Id":386730,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"00093310701"},{"Id":386731,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"00093310705"},{"Id":386732,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"00093310905"},{"Id":386733,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"00093310953"},{"Id":386734,"FormularyType":"OHP","DrugName":"DICLOXACILL CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300020100110","GenericName":"DICLOXACILLIN SODIUM CAP 250 MG","NDC":"00093312301"},{"Id":386735,"FormularyType":"OHP","DrugName":"DICLOXACILL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300020100115","GenericName":"DICLOXACILLIN SODIUM CAP 500 MG","NDC":"00093312501"},{"Id":386736,"FormularyType":"OHP","DrugName":"DISOPYRAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010100105","GenericName":"DISOPYRAMIDE PHOSPHATE CAP 100 MG","NDC":"00093312701"},{"Id":386737,"FormularyType":"OHP","DrugName":"DISOPYRAMIDE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010100110","GenericName":"DISOPYRAMIDE PHOSPHATE CAP 150 MG","NDC":"00093312901"},{"Id":386738,"FormularyType":"OHP","DrugName":"CAMRESE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"00093313482"},{"Id":386739,"FormularyType":"OHP","DrugName":"CAMRESE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"00093313491"},{"Id":386740,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"00093314501"},{"Id":386741,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"00093314505"},{"Id":386742,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"00093314701"},{"Id":386743,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"00093314705"},{"Id":386744,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"00093316006"},{"Id":386745,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"00093317431"},{"Id":386746,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"00093319601"},{"Id":386747,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"00093319653"},{"Id":386748,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"00093321201"},{"Id":386749,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"00093321205"},{"Id":386750,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"00093321301"},{"Id":386751,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"00093321305"},{"Id":386752,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"00093321915"},{"Id":386753,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"00093321930"},{"Id":386754,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"00093321992"},{"Id":386755,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"00093322308"},{"Id":386756,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"00093322397"},{"Id":386757,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"00093323401"},{"Id":386758,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"00093323405"},{"Id":386759,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"00093323410"},{"Id":386760,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 7.5/HR","DosageForm":"PTWK - Patch Weekly","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008825","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 7.5 MCG/HR","NDC":"00093323921"},{"Id":386761,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 7.5/HR","DosageForm":"PTWK - Patch Weekly","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008825","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 7.5 MCG/HR","NDC":"00093323940"},{"Id":386762,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"00093324101"},{"Id":386763,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"00093324201"},{"Id":386764,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"00093324356"},{"Id":386765,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"00093330101"},{"Id":386766,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"00093330105"},{"Id":386767,"FormularyType":"OHP","DrugName":"RECLIPSEN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00093330416"},{"Id":386768,"FormularyType":"OHP","DrugName":"RECLIPSEN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00093330428"},{"Id":386769,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"00093342001"},{"Id":386770,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"00093342201"},{"Id":386771,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"00093342205"},{"Id":386772,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"00093342210"},{"Id":386773,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"00093354143"},{"Id":386774,"FormularyType":"OHP","DrugName":"FLUTIC/SALME INH 55/14","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708010","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 55-14 MCG/ACT","NDC":"00093360782"},{"Id":386775,"FormularyType":"OHP","DrugName":"FLUTIC/SALME INH 113/14","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708015","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 113-14 MCG/ACT","NDC":"00093360882"},{"Id":386776,"FormularyType":"OHP","DrugName":"FLUTIC/SALME INH 232/14","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708025","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 232-14 MCG/ACT","NDC":"00093360982"},{"Id":386777,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"00093365522"},{"Id":386778,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"00093365528"},{"Id":386779,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"00093365621"},{"Id":386780,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"00093365640"},{"Id":386781,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"00093365721"},{"Id":386782,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"00093365740"},{"Id":386783,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"00093365821"},{"Id":386784,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"00093365840"},{"Id":386785,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"00093365921"},{"Id":386786,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"00093365940"},{"Id":386787,"FormularyType":"OHP","DrugName":"VESTURA TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"00093400028"},{"Id":386788,"FormularyType":"OHP","DrugName":"VESTURA TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"00093400062"},{"Id":386789,"FormularyType":"OHP","DrugName":"CEFADROXIL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000305","GenericName":"CEFADROXIL TAB 1 GM","NDC":"00093405953"},{"Id":386790,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"00093406701"},{"Id":386791,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"00093406710"},{"Id":386792,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"00093406801"},{"Id":386793,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"00093406810"},{"Id":386794,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"00093406901"},{"Id":386795,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"00093406905"},{"Id":386796,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"00093406952"},{"Id":386797,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"00093408563"},{"Id":386798,"FormularyType":"OHP","DrugName":"PENICILLN VK SOL 125/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"125","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040102105","GenericName":"PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML","NDC":"00093412573"},{"Id":386799,"FormularyType":"OHP","DrugName":"PENICILLN VK SOL 125/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"125","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040102105","GenericName":"PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML","NDC":"00093412574"},{"Id":386800,"FormularyType":"OHP","DrugName":"PENICILLN VK SOL 250/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040102110","GenericName":"PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML","NDC":"00093412773"},{"Id":386801,"FormularyType":"OHP","DrugName":"PENICILLN VK SOL 250/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040102110","GenericName":"PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML","NDC":"00093412774"},{"Id":386802,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"00093413664"},{"Id":386803,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"00093413673"},{"Id":386804,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"00093413764"},{"Id":386805,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"00093413773"},{"Id":386806,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00093415573"},{"Id":386807,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00093415579"},{"Id":386808,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00093415580"},{"Id":386809,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00093416073"},{"Id":386810,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00093416076"},{"Id":386811,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00093416078"},{"Id":386812,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00093416173"},{"Id":386813,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00093416176"},{"Id":386814,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00093416178"},{"Id":386815,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"00093417573"},{"Id":386816,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"00093417574"},{"Id":386817,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"00093417773"},{"Id":386818,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"00093417774"},{"Id":386819,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107045","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","NDC":"00093504501"},{"Id":386820,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 35MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107055","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","NDC":"00093504601"},{"Id":386821,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"00093505610"},{"Id":386822,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"00093505698"},{"Id":386823,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"00093505705"},{"Id":386824,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"00093505798"},{"Id":386825,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"00093505810"},{"Id":386826,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"00093505898"},{"Id":386827,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"00093505910"},{"Id":386828,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"00093505998"},{"Id":386829,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"00093506001"},{"Id":386830,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"00093506005"},{"Id":386831,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"00093506101"},{"Id":386832,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"00093506105"},{"Id":386833,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"00093506110"},{"Id":386834,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"00093506201"},{"Id":386835,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"00093506205"},{"Id":386836,"FormularyType":"OHP","DrugName":"EFAVIR/EMTRI TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903300320","GenericName":"EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG","NDC":"00093523456"},{"Id":386837,"FormularyType":"OHP","DrugName":"JUNEL FE 24 TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"00093532828"},{"Id":386838,"FormularyType":"OHP","DrugName":"JUNEL FE 24 TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"00093532862"},{"Id":386839,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"00093542088"},{"Id":386840,"FormularyType":"OHP","DrugName":"MIMVEY TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"00093545528"},{"Id":386841,"FormularyType":"OHP","DrugName":"MIMVEY TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"00093545542"},{"Id":386842,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200130","GenericName":"ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV)","NDC":"00093552606"},{"Id":386843,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200140","GenericName":"ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV)","NDC":"00093552706"},{"Id":386844,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200150","GenericName":"ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV)","NDC":"00093552856"},{"Id":386845,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107020","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","NDC":"00093555001"},{"Id":386846,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107030","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","NDC":"00093555101"},{"Id":386847,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107035","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","NDC":"00093555201"},{"Id":386848,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107040","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","NDC":"00093555301"},{"Id":386849,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107050","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","NDC":"00093555401"},{"Id":386850,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 40MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107060","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 40 MG","NDC":"00093556201"},{"Id":386851,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 400MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"400","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030006530","GenericName":"MESALAMINE CAP DR 400 MG","NDC":"00093590786"},{"Id":386852,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"00093593854"},{"Id":386853,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"00093593898"},{"Id":386854,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"00093593985"},{"Id":386855,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"00093593998"},{"Id":386856,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"00093594040"},{"Id":386857,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"00093594098"},{"Id":386858,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.15MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.15","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D520","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000)","NDC":"00093598519"},{"Id":386859,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.15MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.15","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D520","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000)","NDC":"00093598527"},{"Id":386860,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.3MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D540","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","NDC":"00093598619"},{"Id":386861,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.3MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D540","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","NDC":"00093598627"},{"Id":386862,"FormularyType":"OHP","DrugName":"RIVELSA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300350","GenericName":"LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG","NDC":"00093603182"},{"Id":386863,"FormularyType":"OHP","DrugName":"RIVELSA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300350","GenericName":"LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG","NDC":"00093603191"},{"Id":386864,"FormularyType":"OHP","DrugName":"CAMRESE LO TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"00093614882"},{"Id":386865,"FormularyType":"OHP","DrugName":"CAMRESE LO TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"00093614891"},{"Id":386866,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00093681519"},{"Id":386867,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00093681545"},{"Id":386868,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00093681555"},{"Id":386869,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00093681573"},{"Id":386870,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00093681619"},{"Id":386871,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00093681645"},{"Id":386872,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00093681655"},{"Id":386873,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00093681673"},{"Id":386874,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"00093681719"},{"Id":386875,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"00093681773"},{"Id":386876,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"00093716305"},{"Id":386877,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"00093716356"},{"Id":386878,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"00093716398"},{"Id":386879,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"00093716405"},{"Id":386880,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"00093716456"},{"Id":386881,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"00093716498"},{"Id":386882,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"00093727105"},{"Id":386883,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"00093727156"},{"Id":386884,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"00093727198"},{"Id":386885,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"00093727205"},{"Id":386886,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"00093727256"},{"Id":386887,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"00093727298"},{"Id":386888,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"00093727305"},{"Id":386889,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"00093727356"},{"Id":386890,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"00093727398"},{"Id":386891,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"00093729001"},{"Id":386892,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"00093729056"},{"Id":386893,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"00093729501"},{"Id":386894,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"00093729505"},{"Id":386895,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"00093729601"},{"Id":386896,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"00093729605"},{"Id":386897,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00093733401"},{"Id":386898,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00093733405"},{"Id":386899,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"00093735056"},{"Id":386900,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"00093735156"},{"Id":386901,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"00093736710"},{"Id":386902,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"00093736756"},{"Id":386903,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"00093736798"},{"Id":386904,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"00093736810"},{"Id":386905,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"00093736856"},{"Id":386906,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"00093736898"},{"Id":386907,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"00093736910"},{"Id":386908,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"00093736956"},{"Id":386909,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"00093736998"},{"Id":386910,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-250M","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350320","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG","NDC":"00093745501"},{"Id":386911,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-500M","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350325","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG","NDC":"00093745601"},{"Id":386912,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350340","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 5-500 MG","NDC":"00093745701"},{"Id":386913,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"00093747119"},{"Id":386914,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"00093747143"},{"Id":386915,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00093747219"},{"Id":386916,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00093747243"},{"Id":386917,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"00093747306"},{"Id":386918,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"00093747489"},{"Id":386919,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 500/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708040","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/ACT","NDC":"00093751631"},{"Id":386920,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 100/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708020","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/ACT","NDC":"00093751731"},{"Id":386921,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 250/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708030","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/ACT","NDC":"00093751831"},{"Id":386922,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"00093753656"},{"Id":386923,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"00093762056"},{"Id":386924,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"00093762998"},{"Id":386925,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"00093763056"},{"Id":386926,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"00093766256"},{"Id":386927,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"00093766356"},{"Id":386928,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"00093766456"},{"Id":386929,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"00093770456"},{"Id":386930,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000305","GenericName":"FAMCICLOVIR TAB 125 MG","NDC":"00093811756"},{"Id":386931,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000310","GenericName":"FAMCICLOVIR TAB 250 MG","NDC":"00093811856"},{"Id":386932,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000320","GenericName":"FAMCICLOVIR TAB 500 MG","NDC":"00093811956"},{"Id":386933,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"00093818064"},{"Id":386934,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000310","GenericName":"CIMETIDINE TAB 300 MG","NDC":"00093819201"},{"Id":386935,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000310","GenericName":"CIMETIDINE TAB 300 MG","NDC":"00093819205"},{"Id":386936,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"00093819928"},{"Id":386937,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000315","GenericName":"CIMETIDINE TAB 400 MG","NDC":"00093820401"},{"Id":386938,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000315","GenericName":"CIMETIDINE TAB 400 MG","NDC":"00093820405"},{"Id":386939,"FormularyType":"OHP","DrugName":"FINZALA CHW FE 1/20","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"00093821028"},{"Id":386940,"FormularyType":"OHP","DrugName":"FINZALA CHW FE 1/20","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"00093821062"},{"Id":386941,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"00093822428"},{"Id":386942,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"00093822928"},{"Id":386943,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"00093823128"},{"Id":386944,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"00093823256"},{"Id":386945,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"00093823298"},{"Id":386946,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"00093823856"},{"Id":386947,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"00093823898"},{"Id":386948,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000320","GenericName":"CIMETIDINE TAB 800 MG","NDC":"00093830501"},{"Id":386949,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"00093831018"},{"Id":386950,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"00093831019"},{"Id":386951,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"00093831118"},{"Id":386952,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"00093831119"},{"Id":386953,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000305","GenericName":"GLYBURIDE TAB 1.25 MG","NDC":"00093834201"},{"Id":386954,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"00093834301"},{"Id":386955,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"00093834305"},{"Id":386956,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"00093834310"},{"Id":386957,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"00093834398"},{"Id":386958,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"00093834401"},{"Id":386959,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"00093834405"},{"Id":386960,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"00093834410"},{"Id":386961,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"00093834498"},{"Id":386962,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00093867574"},{"Id":386963,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00093867575"},{"Id":386964,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00093867578"},{"Id":386965,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"00093873901"},{"Id":386966,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"00093874001"},{"Id":386967,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"00093874101"},{"Id":386968,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"00093901819"},{"Id":386969,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"00093901865"},{"Id":386970,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 50MG MOD","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300130","GenericName":"CYCLOSPORINE MODIFIED CAP 50 MG","NDC":"00093901919"},{"Id":386971,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 50MG MOD","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300130","GenericName":"CYCLOSPORINE MODIFIED CAP 50 MG","NDC":"00093901965"},{"Id":386972,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"00093902019"},{"Id":386973,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"00093902065"},{"Id":386974,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"00093922489"},{"Id":386975,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"00093936401"},{"Id":386976,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"00093936410"},{"Id":386977,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"00093943301"},{"Id":386978,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000305","GenericName":"GLYBURIDE TAB 1.25 MG","NDC":"00093947753"},{"Id":386979,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"00093970101"},{"Id":386980,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"00093970105"},{"Id":386981,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"00093970201"},{"Id":386982,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"00093970205"},{"Id":386983,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"00093970210"},{"Id":386984,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"00093970301"},{"Id":386985,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"00093970305"},{"Id":386986,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"00093970310"},{"Id":386987,"FormularyType":"OHP","DrugName":"DHS TAR SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00096072804"},{"Id":386988,"FormularyType":"OHP","DrugName":"DHS TAR SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00096072808"},{"Id":386989,"FormularyType":"OHP","DrugName":"DHS TAR GEL SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00096073008"},{"Id":386990,"FormularyType":"OHP","DrugName":"AQUANIL HC LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"00096073204"},{"Id":386991,"FormularyType":"OHP","DrugName":"DHS TAR GEL SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00096073608"},{"Id":386992,"FormularyType":"OHP","DrugName":"DHS TAR SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00096073704"},{"Id":386993,"FormularyType":"OHP","DrugName":"DHS TAR SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00096073708"},{"Id":386994,"FormularyType":"OHP","DrugName":"COVID-19 AT- KIT 1-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"00111070752"},{"Id":386995,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00113002026"},{"Id":386996,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113002562"},{"Id":386997,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113002571"},{"Id":386998,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113002578"},{"Id":386999,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113002925"},{"Id":387000,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113002960"},{"Id":387001,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113002971"},{"Id":387002,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"00113005058"},{"Id":387003,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"00113005060"},{"Id":387004,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00113005306"},{"Id":387005,"FormularyType":"OHP","DrugName":"SUPHEDRINE TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00113005452"},{"Id":387006,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"00113005705"},{"Id":387007,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"00113008100"},{"Id":387008,"FormularyType":"OHP","DrugName":"FIRST AID OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00113008464"},{"Id":387009,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00113014165"},{"Id":387010,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00113016110"},{"Id":387011,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00113016626"},{"Id":387012,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00113016634"},{"Id":387013,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00113017071"},{"Id":387014,"FormularyType":"OHP","DrugName":"WOMENS LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00113017465"},{"Id":387015,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00113018926"},{"Id":387016,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00113019402"},{"Id":387017,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00113019471"},{"Id":387018,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00113019496"},{"Id":387019,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113020625"},{"Id":387020,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00113021226"},{"Id":387021,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE TUBE/KIT","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"00113021429"},{"Id":387022,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00113027408"},{"Id":387023,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00113027468"},{"Id":387024,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00113029827"},{"Id":387025,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00113029858"},{"Id":387026,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00113030601"},{"Id":387027,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00113030602"},{"Id":387028,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00113030603"},{"Id":387029,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00113034405"},{"Id":387030,"FormularyType":"OHP","DrugName":"MIGRAINE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00113037462"},{"Id":387031,"FormularyType":"OHP","DrugName":"MIGRAINE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00113037478"},{"Id":387032,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00113037926"},{"Id":387033,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00113037943"},{"Id":387034,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"00113040378"},{"Id":387035,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00113041693"},{"Id":387036,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00113042225"},{"Id":387037,"FormularyType":"OHP","DrugName":"HEADACHE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00113043071"},{"Id":387038,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"00113043162"},{"Id":387039,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00113043262"},{"Id":387040,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"00113044164"},{"Id":387041,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"00113044173"},{"Id":387042,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"00113044301"},{"Id":387043,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113045660"},{"Id":387044,"FormularyType":"OHP","DrugName":"ALLER-TEC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00113045888"},{"Id":387045,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00113046267"},{"Id":387046,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00113046708"},{"Id":387047,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00113046768"},{"Id":387048,"FormularyType":"OHP","DrugName":"ANTI-ITCH OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"00113047164"},{"Id":387049,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00113047962"},{"Id":387050,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00113047978"},{"Id":387051,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00113047979"},{"Id":387052,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113048462"},{"Id":387053,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113048471"},{"Id":387054,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113048478"},{"Id":387055,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00113048490"},{"Id":387056,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00113050326"},{"Id":387057,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113051771"},{"Id":387058,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"00113052055"},{"Id":387059,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"00113052074"},{"Id":387060,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00113053260"},{"Id":387061,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00113054164"},{"Id":387062,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00113054478"},{"Id":387063,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113060462"},{"Id":387064,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113060471"},{"Id":387065,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113060478"},{"Id":387066,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113060490"},{"Id":387067,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00113060826"},{"Id":387068,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00113061246"},{"Id":387069,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00113061265"},{"Id":387070,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00113061275"},{"Id":387071,"FormularyType":"OHP","DrugName":"ALLERCLEAR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00113061287"},{"Id":387072,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113064762"},{"Id":387073,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113064771"},{"Id":387074,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113064778"},{"Id":387075,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00113066026"},{"Id":387076,"FormularyType":"OHP","DrugName":"ALLERGY RLF LIQ CHILDREN","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00113067126"},{"Id":387077,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00113068526"},{"Id":387078,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00113073402"},{"Id":387079,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"00113082529"},{"Id":387080,"FormularyType":"OHP","DrugName":"ALLER-EASE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00113084795"},{"Id":387081,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00113087305"},{"Id":387082,"FormularyType":"OHP","DrugName":"GOODSENSE TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00113088013"},{"Id":387083,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00113089726"},{"Id":387084,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00113089734"},{"Id":387085,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00113089801"},{"Id":387086,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00113089802"},{"Id":387087,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00113089803"},{"Id":387088,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00113094610"},{"Id":387089,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00113095702"},{"Id":387090,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00113095760"},{"Id":387091,"FormularyType":"OHP","DrugName":"GOODSENSE GEL ART PAIN","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00113118901"},{"Id":387092,"FormularyType":"OHP","DrugName":"GOODSENSE GEL ART PAIN","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00113118903"},{"Id":387093,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113121209"},{"Id":387094,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00113121285"},{"Id":387095,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113135278"},{"Id":387096,"FormularyType":"OHP","DrugName":"GOODSENSE LIQ LICE RIN","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"00113191016"},{"Id":387097,"FormularyType":"OHP","DrugName":"OPTION 2 TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"00113200312"},{"Id":387098,"FormularyType":"OHP","DrugName":"SINUS 12 HR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00113201760"},{"Id":387099,"FormularyType":"OHP","DrugName":"GS IBUPROFEN CHW CHILDREN","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"00113246162"},{"Id":387100,"FormularyType":"OHP","DrugName":"SLEEP AID TAB ULTRA","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"00113403262"},{"Id":387101,"FormularyType":"OHP","DrugName":"SLEEP AID TAB ULTRA","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"00113403267"},{"Id":387102,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00113810025"},{"Id":387103,"FormularyType":"OHP","DrugName":"OPILL TAB 0.075MG","DosageForm":"TABS - Tablet","Strength":"0.075","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100020000305","GenericName":"NORGESTREL TAB 0.075 MG","NDC":"00113810101"},{"Id":387104,"FormularyType":"OHP","DrugName":"OPILL TAB 0.075MG","DosageForm":"TABS - Tablet","Strength":"0.075","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100020000305","GenericName":"NORGESTREL TAB 0.075 MG","NDC":"00113810103"},{"Id":387105,"FormularyType":"OHP","DrugName":"OPILL TAB 0.075MG","DosageForm":"TABS - Tablet","Strength":"0.075","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100020000305","GenericName":"NORGESTREL TAB 0.075 MG","NDC":"00113810104"},{"Id":387106,"FormularyType":"OHP","DrugName":"OPILL TAB 0.075MG","DosageForm":"TABS - Tablet","Strength":"0.075","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100020000305","GenericName":"NORGESTREL TAB 0.075 MG","NDC":"00113810106"},{"Id":387107,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00113860025"},{"Id":387108,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00113895926"},{"Id":387109,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00113945839"},{"Id":387110,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00113945866"},{"Id":387111,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00113945895"},{"Id":387112,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"00115136529"},{"Id":387113,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"00115136530"},{"Id":387114,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"00115136629"},{"Id":387115,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"00115136630"},{"Id":387116,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI TAB ER 180MG","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100405","GenericName":"PYRIDOSTIGMINE BROMIDE TAB ER 180 MG","NDC":"00115140408"},{"Id":387117,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"00115148601"},{"Id":387118,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"00115148701"},{"Id":387119,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"00115148801"},{"Id":387120,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"00115148901"},{"Id":387121,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"00115149001"},{"Id":387122,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"00115149101"},{"Id":387123,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"00115164301"},{"Id":387124,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"00115164501"},{"Id":387125,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00115168774"},{"Id":387126,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00115168776"},{"Id":387127,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00115168974"},{"Id":387128,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00115168976"},{"Id":387129,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"00115169301"},{"Id":387130,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.3MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D540","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","NDC":"00115169430"},{"Id":387131,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.3MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D540","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","NDC":"00115169449"},{"Id":387132,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.15MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.15","BrandVsGeneric":"N","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D530","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML (1:1000)","NDC":"00115169530"},{"Id":387133,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.15MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.15","BrandVsGeneric":"N","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D530","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML (1:1000)","NDC":"00115169549"},{"Id":387134,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"00115169606"},{"Id":387135,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"00115169701"},{"Id":387136,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"00115170001"},{"Id":387137,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107045","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","NDC":"00115170901"},{"Id":387138,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 35MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107055","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","NDC":"00115171001"},{"Id":387139,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 10MG CD","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100210","GenericName":"METHYLPHENIDATE HCL CAP ER 10 MG (CD)","NDC":"00115173601"},{"Id":387140,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 20MG CD","DosageForm":"CPCR - Capsule ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100220","GenericName":"METHYLPHENIDATE HCL CAP ER 20 MG (CD)","NDC":"00115173701"},{"Id":387141,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 30MG CD","DosageForm":"CPCR - Capsule ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100230","GenericName":"METHYLPHENIDATE HCL CAP ER 30 MG (CD)","NDC":"00115173801"},{"Id":387142,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 40MG CD","DosageForm":"CPCR - Capsule ER","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100240","GenericName":"METHYLPHENIDATE HCL CAP ER 40 MG (CD)","NDC":"00115173901"},{"Id":387143,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 50MG CD","DosageForm":"CPCR - Capsule ER","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100250","GenericName":"METHYLPHENIDATE HCL CAP ER 50 MG (CD)","NDC":"00115174001"},{"Id":387144,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 60MG CD","DosageForm":"CPCR - Capsule ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100260","GenericName":"METHYLPHENIDATE HCL CAP ER 60 MG (CD)","NDC":"00115174101"},{"Id":387145,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000110","GenericName":"ACITRETIN CAP 10 MG","NDC":"00115175008"},{"Id":387146,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 17.5MG","DosageForm":"CAPS - Capsule","Strength":"17.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000115","GenericName":"ACITRETIN CAP 17.5 MG","NDC":"00115175108"},{"Id":387147,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000125","GenericName":"ACITRETIN CAP 25 MG","NDC":"00115175308"},{"Id":387148,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"00115175701"},{"Id":387149,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00115180301"},{"Id":387150,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00115180302"},{"Id":387151,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"00115180401"},{"Id":387152,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"00115180402"},{"Id":387153,"FormularyType":"OHP","DrugName":"RIMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12500070100320","GenericName":"RIMANTADINE HYDROCHLORIDE TAB 100 MG","NDC":"00115191101"},{"Id":387154,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"00115202310"},{"Id":387155,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"00115261101"},{"Id":387156,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"00115262201"},{"Id":387157,"FormularyType":"OHP","DrugName":"PYRIDOSTIGM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100305","GenericName":"PYRIDOSTIGMINE BROMIDE TAB 60 MG","NDC":"00115351101"},{"Id":387158,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100105","GenericName":"DANTROLENE SODIUM CAP 25 MG","NDC":"00115441101"},{"Id":387159,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100110","GenericName":"DANTROLENE SODIUM CAP 50 MG","NDC":"00115442201"},{"Id":387160,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100115","GenericName":"DANTROLENE SODIUM CAP 100 MG","NDC":"00115443301"},{"Id":387161,"FormularyType":"OHP","DrugName":"COLESTIPOL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020100320","GenericName":"COLESTIPOL HCL TAB 1 GM","NDC":"00115521116"},{"Id":387162,"FormularyType":"OHP","DrugName":"COLESTIPOL GRA 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020103010","GenericName":"COLESTIPOL HCL GRANULE PACKETS 5 GM","NDC":"00115521218"},{"Id":387163,"FormularyType":"OHP","DrugName":"COLESTIPOL GRA 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020103010","GenericName":"COLESTIPOL HCL GRANULE PACKETS 5 GM","NDC":"00115521229"},{"Id":387164,"FormularyType":"OHP","DrugName":"COLESTIPOL GRA 5GM","DosageForm":"GRAN - Granules","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020102705","GenericName":"COLESTIPOL HCL GRANULES 5 GM","NDC":"00115521302"},{"Id":387165,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"00115551110"},{"Id":387166,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"00115552210"},{"Id":387167,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"00115592201"},{"Id":387168,"FormularyType":"OHP","DrugName":"CHLOROQUINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000010200310","GenericName":"CHLOROQUINE PHOSPHATE TAB 500 MG","NDC":"00115701009"},{"Id":387169,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"00115703301"},{"Id":387170,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"00115703302"},{"Id":387171,"FormularyType":"OHP","DrugName":"METHITEST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100020000310","GenericName":"METHYLTESTOSTERONE ORAL TAB 10 MG","NDC":"00115703701"},{"Id":387172,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107020","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","NDC":"00115991801"},{"Id":387173,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107030","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","NDC":"00115991901"},{"Id":387174,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107035","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","NDC":"00115992001"},{"Id":387175,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107040","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","NDC":"00115992101"},{"Id":387176,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107050","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","NDC":"00115992201"},{"Id":387177,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00116200104"},{"Id":387178,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00116200106"},{"Id":387179,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00116200107"},{"Id":387180,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00116200115"},{"Id":387181,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00116200116"},{"Id":387182,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400508"},{"Id":387183,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400511"},{"Id":387184,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400515"},{"Id":387185,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400516"},{"Id":387186,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400530"},{"Id":387187,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400532"},{"Id":387188,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400540"},{"Id":387189,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00116400541"},{"Id":387190,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"00116401010"},{"Id":387191,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"00116401016"},{"Id":387192,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"00116401041"},{"Id":387193,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"00116402316"},{"Id":387194,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"00116402550"},{"Id":387195,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS","DosageForm":"SUSP - Suspension","Strength":"7.75","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00121043130"},{"Id":387196,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM ELX 12.5/5ML","DosageForm":"ELIX - Elixir","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030101010","GenericName":"DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML","NDC":"00121048900"},{"Id":387197,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM ELX 12.5/5ML","DosageForm":"ELIX - Elixir","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030101010","GenericName":"DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML","NDC":"00121048905"},{"Id":387198,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"00121053005"},{"Id":387199,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"00121059500"},{"Id":387200,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"00121059515"},{"Id":387201,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"00121059516"},{"Id":387202,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"00121064610"},{"Id":387203,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"00121064616"},{"Id":387204,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN SOL 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"N","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070102005","GenericName":"TRIHEXYPHENIDYL HCL ORAL SOLN 0.4 MG/ML","NDC":"00121065816"},{"Id":387205,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010002005","GenericName":"ETHOSUXIMIDE SOLN 250 MG/5ML","NDC":"00121067016"},{"Id":387206,"FormularyType":"OHP","DrugName":"K CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202022002025","GenericName":"POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML","NDC":"00121067616"},{"Id":387207,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202020","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)","NDC":"00121075908"},{"Id":387208,"FormularyType":"OHP","DrugName":"CALCIUM CARB SUS 1250/5ML","DosageForm":"SUSP - Suspension","Strength":"1250","BrandVsGeneric":"N","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010001815","GenericName":"CALCIUM CARBONATE (ANTACID) SUSP 1250 MG/5ML","NDC":"00121076616"},{"Id":387209,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00121079916"},{"Id":387210,"FormularyType":"OHP","DrugName":"THEOPHYLLINE ELX 80/15ML","DosageForm":"ELIX - Elixir","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040001010","GenericName":"THEOPHYLLINE ELIXIR 80 MG/15ML","NDC":"00121082016"},{"Id":387211,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00121083300"},{"Id":387212,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00121083305"},{"Id":387213,"FormularyType":"OHP","DrugName":"SULFATRIM PD SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"00121085416"},{"Id":387214,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00121086500"},{"Id":387215,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"00121086800"},{"Id":387216,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"00121086802"},{"Id":387217,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"00121086816"},{"Id":387218,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"00121086850"},{"Id":387219,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121087316"},{"Id":387220,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121087332"},{"Id":387221,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00121087404"},{"Id":387222,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00121087416"},{"Id":387223,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"00121088508"},{"Id":387224,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"00121088516"},{"Id":387225,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00121089300"},{"Id":387226,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00121089340"},{"Id":387227,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00121093505"},{"Id":387228,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00121093540"},{"Id":387229,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/10","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101860","GenericName":"MAGNESIUM HYDROXIDE SUSP CONCENTRATE 2400 MG/10ML","NDC":"00121094000"},{"Id":387230,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/10","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101860","GenericName":"MAGNESIUM HYDROXIDE SUSP CONCENTRATE 2400 MG/10ML","NDC":"00121094010"},{"Id":387231,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121094205"},{"Id":387232,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121094216"},{"Id":387233,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121094250"},{"Id":387234,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00121094500"},{"Id":387235,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00121094510"},{"Id":387236,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00121094540"},{"Id":387237,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121094816"},{"Id":387238,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% VISC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"00121095003"},{"Id":387239,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"00121095608"},{"Id":387240,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00121096600"},{"Id":387241,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00121096605"},{"Id":387242,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"00121097251"},{"Id":387243,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00121097400"},{"Id":387244,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00121097440"},{"Id":387245,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00121097450"},{"Id":387246,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00121097494"},{"Id":387247,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM ELX 12.5/5ML","DosageForm":"ELIX - Elixir","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030101010","GenericName":"DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML","NDC":"00121097800"},{"Id":387248,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM ELX 12.5/5ML","DosageForm":"ELIX - Elixir","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030101010","GenericName":"DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML","NDC":"00121097810"},{"Id":387249,"FormularyType":"OHP","DrugName":"APAP/CODEINE SOL 300-30MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002052020","GenericName":"ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML","NDC":"00121100812"},{"Id":387250,"FormularyType":"OHP","DrugName":"APAP/CODEINE SOL 300-30MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002052020","GenericName":"ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML","NDC":"00121100840"},{"Id":387251,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 50/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121101205"},{"Id":387252,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 50/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121101295"},{"Id":387253,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"00121101618"},{"Id":387254,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"00121101642"},{"Id":387255,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"00121101830"},{"Id":387256,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"00121101930"},{"Id":387257,"FormularyType":"OHP","DrugName":"CIMETIDINE SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200010102050","GenericName":"CIMETIDINE HCL SOLN 300 MG/5ML","NDC":"00121102508"},{"Id":387258,"FormularyType":"OHP","DrugName":"HYDROXYZINE SYP 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"00121103416"},{"Id":387259,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400/10ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00121103800"},{"Id":387260,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400/10ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00121103840"},{"Id":387261,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00121104700"},{"Id":387262,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00121104705"},{"Id":387263,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"00121106716"},{"Id":387264,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"00121107601"},{"Id":387265,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"00121107650"},{"Id":387266,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121115400"},{"Id":387267,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121115430"},{"Id":387268,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121115440"},{"Id":387269,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"00121119000"},{"Id":387270,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"00121119030"},{"Id":387271,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 5-217MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"00121154410"},{"Id":387272,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 5-217MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"00121154440"},{"Id":387273,"FormularyType":"OHP","DrugName":"METOCLOPRAM SOL 10/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102013","GenericName":"METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","NDC":"00121157610"},{"Id":387274,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00121159810"},{"Id":387275,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00121159820"},{"Id":387276,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 200/10ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00121166600"},{"Id":387277,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 200/10ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00121166610"},{"Id":387278,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00121173000"},{"Id":387279,"FormularyType":"OHP","DrugName":"MAG-AL PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00121176130"},{"Id":387280,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"00121185416"},{"Id":387281,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00121187000"},{"Id":387282,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00121187010"},{"Id":387283,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00121188200"},{"Id":387284,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00121188211"},{"Id":387285,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 30/7.5ML","DosageForm":"ELIX - Elixir","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121188407"},{"Id":387286,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 30/7.5ML","DosageForm":"ELIX - Elixir","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121188450"},{"Id":387287,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121189600"},{"Id":387288,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121189630"},{"Id":387289,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121189640"},{"Id":387290,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121189650"},{"Id":387291,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121202410"},{"Id":387292,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121202495"},{"Id":387293,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"00121203630"},{"Id":387294,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"00121203830"},{"Id":387295,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00121209400"},{"Id":387296,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00121209411"},{"Id":387297,"FormularyType":"OHP","DrugName":"LEUPROLIDE KIT 14 DAY","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"00121210602"},{"Id":387298,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 300/6ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"00121213406"},{"Id":387299,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 300/6ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"00121213440"},{"Id":387300,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"00121231615"},{"Id":387301,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"00121231650"},{"Id":387302,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00121282321"},{"Id":387303,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00121282394"},{"Id":387304,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 60/15ML","DosageForm":"ELIX - Elixir","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121282615"},{"Id":387305,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 60/15ML","DosageForm":"ELIX - Elixir","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"00121282650"},{"Id":387306,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"00121284716"},{"Id":387307,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 150/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121303615"},{"Id":387308,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 150/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121303695"},{"Id":387309,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650/20.3","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00121314100"},{"Id":387310,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650/20.3","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00121314121"},{"Id":387311,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 200/20ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121404874"},{"Id":387312,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 200/20ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00121404895"},{"Id":387313,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"00121406705"},{"Id":387314,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"00121406740"},{"Id":387315,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121457715"},{"Id":387316,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00121457740"},{"Id":387317,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202020","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)","NDC":"00121475905"},{"Id":387318,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202020","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)","NDC":"00121475950"},{"Id":387319,"FormularyType":"OHP","DrugName":"CALCIUM CARB SUS 1250/5ML","DosageForm":"SUSP - Suspension","Strength":"1250","BrandVsGeneric":"N","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010001815","GenericName":"CALCIUM CARBONATE (ANTACID) SUSP 1250 MG/5ML","NDC":"00121476605"},{"Id":387320,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"00121477205"},{"Id":387321,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"00121477240"},{"Id":387322,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00121479940"},{"Id":387323,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00121479950"},{"Id":387324,"FormularyType":"OHP","DrugName":"THEOPHYLLINE ELX 80/15ML","DosageForm":"ELIX - Elixir","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040001010","GenericName":"THEOPHYLLINE ELIXIR 80 MG/15ML","NDC":"00121482015"},{"Id":387325,"FormularyType":"OHP","DrugName":"THEOPHYLLINE ELX 80/15ML","DosageForm":"ELIX - Elixir","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040001010","GenericName":"THEOPHYLLINE ELIXIR 80 MG/15ML","NDC":"00121482040"},{"Id":387326,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00121482705"},{"Id":387327,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00121482740"},{"Id":387328,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00121482750"},{"Id":387329,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121494800"},{"Id":387330,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121494815"},{"Id":387331,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121494840"},{"Id":387332,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121494850"},{"Id":387333,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121494880"},{"Id":387334,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00121494894"},{"Id":387335,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% ORAL","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"00121495015"},{"Id":387336,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% ORAL","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"00121495040"},{"Id":387337,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"00121495505"},{"Id":387338,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"00121495594"},{"Id":387339,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"00121496705"},{"Id":387340,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"00121496740"},{"Id":387341,"FormularyType":"OHP","DrugName":"PREVDNT 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"00126007292"},{"Id":387342,"FormularyType":"OHP","DrugName":"PREVDNT 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"00126007492"},{"Id":387343,"FormularyType":"OHP","DrugName":"PERIOGARD SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00126027216"},{"Id":387344,"FormularyType":"OHP","DrugName":"PREVDNT 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"00126028992"},{"Id":387345,"FormularyType":"OHP","DrugName":"PREVDNT 5000 PST 1.1% KID","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"00126031192"},{"Id":387346,"FormularyType":"OHP","DrugName":"FLEET LAXATI OIL MINERAL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"00132000046"},{"Id":387347,"FormularyType":"OHP","DrugName":"PEDIA-LAX LIQ 50MG","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300903","GenericName":"DOCUSATE SODIUM LIQUID 50 MG/15ML","NDC":"00132000106"},{"Id":387348,"FormularyType":"OHP","DrugName":"FLEET SALINE ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00132002011"},{"Id":387349,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007512"},{"Id":387350,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007524"},{"Id":387351,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007550"},{"Id":387352,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007900"},{"Id":387353,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007912"},{"Id":387354,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007924"},{"Id":387355,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"00132007950"},{"Id":387356,"FormularyType":"OHP","DrugName":"PEDIA-LAX LIQ 50MG","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300903","GenericName":"DOCUSATE SODIUM LIQUID 50 MG/15ML","NDC":"00132010624"},{"Id":387357,"FormularyType":"OHP","DrugName":"FLEET ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00132011946"},{"Id":387358,"FormularyType":"OHP","DrugName":"FLEET LIQUID ENE GLYCERIN","DosageForm":"ENEM - Enema","Strength":"5.4","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005120","GenericName":"GLYCERIN ENEMA ADULT 5.4 GM/AVERAGE DELIVERED DOSE","NDC":"00132018501"},{"Id":387359,"FormularyType":"OHP","DrugName":"FLEET LIQUID ENE GLYCERIN","DosageForm":"ENEM - Enema","Strength":"5.4","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005120","GenericName":"GLYCERIN ENEMA ADULT 5.4 GM/AVERAGE DELIVERED DOSE","NDC":"00132018582"},{"Id":387360,"FormularyType":"OHP","DrugName":"FLEET ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00132020140"},{"Id":387361,"FormularyType":"OHP","DrugName":"FLEET ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00132020142"},{"Id":387362,"FormularyType":"OHP","DrugName":"FLEET ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00132020145"},{"Id":387363,"FormularyType":"OHP","DrugName":"FLEET ENE PED","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105110","GenericName":"*SODIUM PHOSPHATES - ENEMA (PEDIATRIC)***","NDC":"00132020220"},{"Id":387364,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00136314753"},{"Id":387365,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"00143117101"},{"Id":387366,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"00143117110"},{"Id":387367,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"00143117201"},{"Id":387368,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"00143117210"},{"Id":387369,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"00143117301"},{"Id":387370,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"00143117310"},{"Id":387371,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"00143117401"},{"Id":387372,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00143122701"},{"Id":387373,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00143122710"},{"Id":387374,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"00143124001"},{"Id":387375,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"00143124010"},{"Id":387376,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"00143124101"},{"Id":387377,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"00143124110"},{"Id":387378,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"00143145501"},{"Id":387379,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"00143145505"},{"Id":387380,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"00143145801"},{"Id":387381,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"00143145805"},{"Id":387382,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"00143149501"},{"Id":387383,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"00143149505"},{"Id":387384,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"00143150001"},{"Id":387385,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"00143150005"},{"Id":387386,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"00143176901"},{"Id":387387,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"00143177101"},{"Id":387388,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"00143177201"},{"Id":387389,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"00143211205"},{"Id":387390,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"00143211250"},{"Id":387391,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00143900501"},{"Id":387392,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 80MG/2ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"00143912801"},{"Id":387393,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 80MG/2ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"00143912825"},{"Id":387394,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102119","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 2 GM","NDC":"00143913901"},{"Id":387395,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102119","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 2 GM","NDC":"00143913925"},{"Id":387396,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"3","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102121","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 3 GM","NDC":"00143914001"},{"Id":387397,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"3","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102121","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 3 GM","NDC":"00143914025"},{"Id":387398,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"00143914402"},{"Id":387399,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"00143914403"},{"Id":387400,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"00143915201"},{"Id":387401,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"00143915210"},{"Id":387402,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"00143915301"},{"Id":387403,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"00143915310"},{"Id":387404,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915501"},{"Id":387405,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915525"},{"Id":387406,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915601"},{"Id":387407,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915610"},{"Id":387408,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915701"},{"Id":387409,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915710"},{"Id":387410,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 500/50ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915801"},{"Id":387411,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 1000/100","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00143915901"},{"Id":387412,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"00143916110"},{"Id":387413,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"00143916125"},{"Id":387414,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00143916201"},{"Id":387415,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00143916210"},{"Id":387416,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"00143916301"},{"Id":387417,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"00143916401"},{"Id":387418,"FormularyType":"OHP","DrugName":"STARJEMZA INJ 45/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"45","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025058581E520","GenericName":"USTEKINUMAB-HMNY SOLN PREFILLED SYRINGE 45 MG/0.5ML","NDC":"00143916801"},{"Id":387419,"FormularyType":"OHP","DrugName":"STARJEMZA INJ 90MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"90","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025058581E540","GenericName":"USTEKINUMAB-HMNY SOLN PREFILLED SYRINGE 90 MG/ML","NDC":"00143917001"},{"Id":387420,"FormularyType":"OHP","DrugName":"BENZTROPINE INJ 2MG/2ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010102005","GenericName":"BENZTROPINE MESYLATE INJ 1 MG/ML","NDC":"00143923301"},{"Id":387421,"FormularyType":"OHP","DrugName":"BENZTROPINE INJ 2MG/2ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010102005","GenericName":"BENZTROPINE MESYLATE INJ 1 MG/ML","NDC":"00143923305"},{"Id":387422,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"00143924920"},{"Id":387423,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"00143926101"},{"Id":387424,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"00143926110"},{"Id":387425,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"00143926201"},{"Id":387426,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"00143926225"},{"Id":387427,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 300/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312020","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 300 MG/50ML","NDC":"00143926701"},{"Id":387428,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00143926801"},{"Id":387429,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00143926901"},{"Id":387430,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"00143928501"},{"Id":387431,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"00143928520"},{"Id":387432,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 10MG/ML","DosageForm":"OIL - Oil","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201705","GenericName":"ESTRADIOL VALERATE IM IN OIL 10 MG/ML","NDC":"00143928901"},{"Id":387433,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 20MG/ML","DosageForm":"OIL - Oil","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201710","GenericName":"ESTRADIOL VALERATE IM IN OIL 20 MG/ML","NDC":"00143929001"},{"Id":387434,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 40MG/ML","DosageForm":"OIL - Oil","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201715","GenericName":"ESTRADIOL VALERATE IM IN OIL 40 MG/ML","NDC":"00143929101"},{"Id":387435,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"00143931501"},{"Id":387436,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"00143931524"},{"Id":387437,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"00143931601"},{"Id":387438,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"00143931624"},{"Id":387439,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"00143931701"},{"Id":387440,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"00143931724"},{"Id":387441,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"00143935501"},{"Id":387442,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"00143935510"},{"Id":387443,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00143935701"},{"Id":387444,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00143935710"},{"Id":387445,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"00143935801"},{"Id":387446,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"00143935901"},{"Id":387447,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102150","GenericName":"METHOTREXATE SODIUM FOR INJ 1 GM","NDC":"00143936701"},{"Id":387448,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"00143938201"},{"Id":387449,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"00143938210"},{"Id":387450,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"00143938301"},{"Id":387451,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"00143938310"},{"Id":387452,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"00143938701"},{"Id":387453,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"00143938725"},{"Id":387454,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"00143939801"},{"Id":387455,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"00143939810"},{"Id":387456,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"00143942901"},{"Id":387457,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"00143942910"},{"Id":387458,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00143943001"},{"Id":387459,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00143943010"},{"Id":387460,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00143943101"},{"Id":387461,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00143943110"},{"Id":387462,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"00143944301"},{"Id":387463,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"00143944312"},{"Id":387464,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 50MG/2ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102063","GenericName":"METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML)","NDC":"00143951901"},{"Id":387465,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 50MG/2ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102063","GenericName":"METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML)","NDC":"00143951910"},{"Id":387466,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"00143953401"},{"Id":387467,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"00143953410"},{"Id":387468,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102115","GenericName":"CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","NDC":"00143956701"},{"Id":387469,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102115","GenericName":"CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","NDC":"00143956725"},{"Id":387470,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102105","GenericName":"CEFUROXIME SODIUM FOR INJ 750 MG","NDC":"00143956801"},{"Id":387471,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102105","GenericName":"CEFUROXIME SODIUM FOR INJ 750 MG","NDC":"00143956825"},{"Id":387472,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"00143959721"},{"Id":387473,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00143961901"},{"Id":387474,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00143961910"},{"Id":387475,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00143962001"},{"Id":387476,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00143962010"},{"Id":387477,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00143962101"},{"Id":387478,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00143962125"},{"Id":387479,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"00143963801"},{"Id":387480,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"00143963805"},{"Id":387481,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00143965901"},{"Id":387482,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102125","GenericName":"CEFTRIAXONE SODIUM FOR INJ 10 GM","NDC":"00143967801"},{"Id":387483,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"00143972001"},{"Id":387484,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"00143972024"},{"Id":387485,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"00143972101"},{"Id":387486,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"00143972124"},{"Id":387487,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"00143972201"},{"Id":387488,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"00143972224"},{"Id":387489,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00143972601"},{"Id":387490,"FormularyType":"OHP","DrugName":"BENZTROPINE INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010102005","GenericName":"BENZTROPINE MESYLATE INJ 1 MG/ML","NDC":"00143972901"},{"Id":387491,"FormularyType":"OHP","DrugName":"BENZTROPINE INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010102005","GenericName":"BENZTROPINE MESYLATE INJ 1 MG/ML","NDC":"00143972905"},{"Id":387492,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102010","GenericName":"GRANISETRON HCL INJ 1 MG/ML","NDC":"00143974401"},{"Id":387493,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102010","GenericName":"GRANISETRON HCL INJ 1 MG/ML","NDC":"00143974410"},{"Id":387494,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 4MG/4ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102015","GenericName":"GRANISETRON HCL INJ 4 MG/4ML (1 MG/ML)","NDC":"00143974501"},{"Id":387495,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 4MG/4ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102015","GenericName":"GRANISETRON HCL INJ 4 MG/4ML (1 MG/ML)","NDC":"00143974505"},{"Id":387496,"FormularyType":"OHP","DrugName":"TESTOST ENAN INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030202010","GenericName":"TESTOSTERONE ENANTHATE IM INJ IN OIL 200 MG/ML","NDC":"00143975001"},{"Id":387497,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"00143975301"},{"Id":387498,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"00143975325"},{"Id":387499,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"00143980250"},{"Id":387500,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"00143980305"},{"Id":387501,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"00143980350"},{"Id":387502,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102150","GenericName":"METHOTREXATE SODIUM FOR INJ 1 GM","NDC":"00143983001"},{"Id":387503,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"00143983601"},{"Id":387504,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"00143983610"},{"Id":387505,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"00143983701"},{"Id":387506,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"00143983710"},{"Id":387507,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00143985316"},{"Id":387508,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00143985324"},{"Id":387509,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00143985375"},{"Id":387510,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00143985601"},{"Id":387511,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00143985625"},{"Id":387512,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00143985701"},{"Id":387513,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00143985725"},{"Id":387514,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00143985801"},{"Id":387515,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00143985825"},{"Id":387516,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00143985901"},{"Id":387517,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00143985925"},{"Id":387518,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"00143987501"},{"Id":387519,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"00143987510"},{"Id":387520,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"00143987525"},{"Id":387521,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102117","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 10 GM","NDC":"00143987610"},{"Id":387522,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"00143987701"},{"Id":387523,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"00143987725"},{"Id":387524,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"00143987801"},{"Id":387525,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"00143987825"},{"Id":387526,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00143988601"},{"Id":387527,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00143988650"},{"Id":387528,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00143988675"},{"Id":387529,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00143988701"},{"Id":387530,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00143988750"},{"Id":387531,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00143988775"},{"Id":387532,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"00143988801"},{"Id":387533,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"00143988815"},{"Id":387534,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"00143988880"},{"Id":387535,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00143988901"},{"Id":387536,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00143988915"},{"Id":387537,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00143988980"},{"Id":387538,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102110","GenericName":"CEFAZOLIN SODIUM FOR INJ 500 MG","NDC":"00143992390"},{"Id":387539,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"00143992490"},{"Id":387540,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"00143992701"},{"Id":387541,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"00143992801"},{"Id":387542,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"00143992950"},{"Id":387543,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"00143993905"},{"Id":387544,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102115","GenericName":"CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","NDC":"00143997722"},{"Id":387545,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102115","GenericName":"CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","NDC":"00143997790"},{"Id":387546,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102105","GenericName":"CEFUROXIME SODIUM FOR INJ 750 MG","NDC":"00143997922"},{"Id":387547,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102105","GenericName":"CEFUROXIME SODIUM FOR INJ 750 MG","NDC":"00143997990"},{"Id":387548,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00143998101"},{"Id":387549,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00143998150"},{"Id":387550,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00143998175"},{"Id":387551,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00143998201"},{"Id":387552,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00143998250"},{"Id":387553,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00143998275"},{"Id":387554,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"00143998303"},{"Id":387555,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"00143998391"},{"Id":387556,"FormularyType":"OHP","DrugName":"SARNOL-HC LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"00145062202"},{"Id":387557,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103720","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.5%","NDC":"00168000215"},{"Id":387558,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"00168000315"},{"Id":387559,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"00168000380"},{"Id":387560,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"00168000415"},{"Id":387561,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"00168000416"},{"Id":387562,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"00168000480"},{"Id":387563,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"00168000580"},{"Id":387564,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"00168000615"},{"Id":387565,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"00168000616"},{"Id":387566,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"00168000680"},{"Id":387567,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00168001516"},{"Id":387568,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00168001531"},{"Id":387569,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"00168002016"},{"Id":387570,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"00168002031"},{"Id":387571,"FormularyType":"OHP","DrugName":"BETAMETH VAL OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020104205","GenericName":"BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT)","NDC":"00168003315"},{"Id":387572,"FormularyType":"OHP","DrugName":"BETAMETH VAL OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020104205","GenericName":"BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT)","NDC":"00168003346"},{"Id":387573,"FormularyType":"OHP","DrugName":"BETAMETH VAL CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020103710","GenericName":"BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","NDC":"00168004015"},{"Id":387574,"FormularyType":"OHP","DrugName":"BETAMETH VAL CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020103710","GenericName":"BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","NDC":"00168004046"},{"Id":387575,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"00168005515"},{"Id":387576,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"00168005546"},{"Id":387577,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"00168005615"},{"Id":387578,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"00168005646"},{"Id":387579,"FormularyType":"OHP","DrugName":"BETAMETH DIP LOT 0.05%","DosageForm":"LOTN - Lotion","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004105","GenericName":"BETAMETHASONE DIPROPIONATE LOTION 0.05%","NDC":"00168005760"},{"Id":387580,"FormularyType":"OHP","DrugName":"FLUOCINOLONE SOL 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550055102005","GenericName":"FLUOCINOLONE ACETONIDE SOLN 0.01%","NDC":"00168005960"},{"Id":387581,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"00168008016"},{"Id":387582,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"00168008031"},{"Id":387583,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"00168009915"},{"Id":387584,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"00168009930"},{"Id":387585,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"00168009960"},{"Id":387586,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00168013330"},{"Id":387587,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00168013346"},{"Id":387588,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"00168013460"},{"Id":387589,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 2.5%","DosageForm":"OINT - Ointment","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004215","GenericName":"HYDROCORTISONE OINT 2.5%","NDC":"00168014616"},{"Id":387590,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 2.5%","DosageForm":"OINT - Ointment","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004215","GenericName":"HYDROCORTISONE OINT 2.5%","NDC":"00168014630"},{"Id":387591,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00168016215"},{"Id":387592,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00168016230"},{"Id":387593,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00168016246"},{"Id":387594,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00168016260"},{"Id":387595,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"00168016315"},{"Id":387596,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"00168016330"},{"Id":387597,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"00168016346"},{"Id":387598,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"00168016360"},{"Id":387599,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"00168020130"},{"Id":387600,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"00168020160"},{"Id":387601,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"00168020230"},{"Id":387602,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"00168020260"},{"Id":387603,"FormularyType":"OHP","DrugName":"CLINDAMYCIN LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104105","GenericName":"CLINDAMYCIN PHOSPHATE LOTION 1%","NDC":"00168020360"},{"Id":387604,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE DIPROP","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"00168025815"},{"Id":387605,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE DIPROP","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"00168025846"},{"Id":387606,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"00168026950"},{"Id":387607,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CRE 2% VAG","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100018103720","GenericName":"CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2%","NDC":"00168027740"},{"Id":387608,"FormularyType":"OHP","DrugName":"METRONIDAZOL CRE 0.75%","DosageForm":"CREA - Cream","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040003710","GenericName":"METRONIDAZOLE CREAM 0.75%","NDC":"00168032346"},{"Id":387609,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"00168033215"},{"Id":387610,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"00168033230"},{"Id":387611,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"00168033260"},{"Id":387612,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"00168035730"},{"Id":387613,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"00168035755"},{"Id":387614,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"00168041630"},{"Id":387615,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"00168041660"},{"Id":387616,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"00168041699"},{"Id":387617,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"00168041730"},{"Id":387618,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"00168041760"},{"Id":387619,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"00168041799"},{"Id":387620,"FormularyType":"OHP","DrugName":"NOVOLIN R INJ RELION","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104010002005","GenericName":"INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML","NDC":"00169183302"},{"Id":387621,"FormularyType":"OHP","DrugName":"NOVOLIN R INJ U-100","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104010002005","GenericName":"INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML","NDC":"00169183311"},{"Id":387622,"FormularyType":"OHP","DrugName":"NOVOLIN N INJ RELION","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104020001805","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML","NDC":"00169183402"},{"Id":387623,"FormularyType":"OHP","DrugName":"NOVOLIN N INJ U-100","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104020001805","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML","NDC":"00169183411"},{"Id":387624,"FormularyType":"OHP","DrugName":"NOVOLIN70/30 INJ RELION","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104090001810","GenericName":"INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30)","NDC":"00169183702"},{"Id":387625,"FormularyType":"OHP","DrugName":"NOVOLIN INJ 70/30","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104090001810","GenericName":"INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30)","NDC":"00169183711"},{"Id":387626,"FormularyType":"OHP","DrugName":"NOVOFINE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"00169185189"},{"Id":387627,"FormularyType":"OHP","DrugName":"NOVOFINE PLS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"00169185550"},{"Id":387628,"FormularyType":"OHP","DrugName":"NOVOLOG RELI INJ 70/30","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104070001820","GenericName":"INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30)","NDC":"00169220011"},{"Id":387629,"FormularyType":"OHP","DrugName":"NOVOLOG MIX INJ FLEX REL","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710407000D320","GenericName":"INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ML (70-30)","NDC":"00169220125"},{"Id":387630,"FormularyType":"OHP","DrugName":"NOVOLIN R INJ 100 UNIT","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710401000D220","GenericName":"INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00169300301"},{"Id":387631,"FormularyType":"OHP","DrugName":"NOVOLIN R INJ 100 UNIT","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710401000D220","GenericName":"INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00169300312"},{"Id":387632,"FormularyType":"OHP","DrugName":"NOVOLIN R INJ 100 UNIT","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710401000D220","GenericName":"INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00169300315"},{"Id":387633,"FormularyType":"OHP","DrugName":"NOVOLIN R INJ 100 UNIT","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710401000D220","GenericName":"INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"00169300325"},{"Id":387634,"FormularyType":"OHP","DrugName":"NOVOLIN N INJ 100 UNIT","DosageForm":"SUPN - Susp Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710402000D320","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML","NDC":"00169300415"},{"Id":387635,"FormularyType":"OHP","DrugName":"NOVOLIN N INJ 100 UNIT","DosageForm":"SUPN - Susp Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710402000D320","GenericName":"INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML","NDC":"00169300425"},{"Id":387636,"FormularyType":"OHP","DrugName":"NOVOLIN INJ 70/30 FP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710409000D320","GenericName":"INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","NDC":"00169300701"},{"Id":387637,"FormularyType":"OHP","DrugName":"NOVOLIN INJ 70/30 FP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710409000D320","GenericName":"INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","NDC":"00169300712"},{"Id":387638,"FormularyType":"OHP","DrugName":"NOVOLIN INJ 70/30 FP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710409000D320","GenericName":"INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","NDC":"00169300715"},{"Id":387639,"FormularyType":"OHP","DrugName":"NOVOLIN INJ 70/30 FP","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710409000D320","GenericName":"INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","NDC":"00169300725"},{"Id":387640,"FormularyType":"OHP","DrugName":"NOVOLOG MIX INJ 70/30","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104070001820","GenericName":"INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30)","NDC":"00169368512"},{"Id":387641,"FormularyType":"OHP","DrugName":"NOVOLOG MIX INJ FLEXPEN","DosageForm":"SUPN - Susp Pen-inj","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710407000D320","GenericName":"INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ML (70-30)","NDC":"00169369619"},{"Id":387642,"FormularyType":"OHP","DrugName":"OZEMPIC INJ 4MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717007000D222","GenericName":"SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (4 MG/3ML)","NDC":"00169413001"},{"Id":387643,"FormularyType":"OHP","DrugName":"OZEMPIC INJ 4MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717007000D222","GenericName":"SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (4 MG/3ML)","NDC":"00169413013"},{"Id":387644,"FormularyType":"OHP","DrugName":"OZEMPIC INJ 2MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717007000D221","GenericName":"SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/3ML)","NDC":"00169418113"},{"Id":387645,"FormularyType":"OHP","DrugName":"WEGOVY INJ 1MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125207000D530","GenericName":"SEMAGLUTIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 1 MG/0.5ML","NDC":"00169450114"},{"Id":387646,"FormularyType":"OHP","DrugName":"WEGOVY INJ 0.5MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125207000D525","GenericName":"SEMAGLUTIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 0.5 MG/0.5ML","NDC":"00169450514"},{"Id":387647,"FormularyType":"OHP","DrugName":"WEGOVY INJ 1.7MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1.7","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125207000D535","GenericName":"SEMAGLUTIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 1.7 MG/0.75ML","NDC":"00169451714"},{"Id":387648,"FormularyType":"OHP","DrugName":"WEGOVY INJ 2.4MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"2.4","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125207000D540","GenericName":"SEMAGLUTIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 2.4 MG/0.75ML","NDC":"00169452414"},{"Id":387649,"FormularyType":"OHP","DrugName":"WEGOVY INJ 0.25MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANTI-OBESITY AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6125207000D520","GenericName":"SEMAGLUTIDE (WEIGHT MNGMT) SOLN AUTO-INJECTOR 0.25 MG/0.5ML","NDC":"00169452514"},{"Id":387650,"FormularyType":"OHP","DrugName":"OZEMPIC INJ 8MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"8","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717007000D225","GenericName":"SEMAGLUTIDE SOLN PEN-INJ 2 MG/DOSE (8 MG/3ML)","NDC":"00169477211"},{"Id":387651,"FormularyType":"OHP","DrugName":"OZEMPIC INJ 8MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"8","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717007000D225","GenericName":"SEMAGLUTIDE SOLN PEN-INJ 2 MG/DOSE (8 MG/3ML)","NDC":"00169477212"},{"Id":387652,"FormularyType":"OHP","DrugName":"RIVFLOZA INJ 160MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"160","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"HYPEROXALURIA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5662605060E530","GenericName":"NEDOSIRAN SODIUM SUBCUTANEOUS SOLN PREF SYR 160 MG/ML","NDC":"00169530610"},{"Id":387653,"FormularyType":"OHP","DrugName":"RIVFLOZA INJ 128/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"128","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"HYPEROXALURIA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5662605060E520","GenericName":"NEDOSIRAN SODIUM SUBCUTANEOUS SOLN PREF SYR 128 MG/0.8ML","NDC":"00169530708"},{"Id":387654,"FormularyType":"OHP","DrugName":"RIVFLOZA INJ 80/0.5ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"HYPEROXALURIA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56626050602020","GenericName":"NEDOSIRAN SODIUM SUBCUTANEOUS SOLN 80 MG/0.5ML","NDC":"00169530801"},{"Id":387655,"FormularyType":"OHP","DrugName":"NORDITROPIN INJ 5/1.5ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000D212","GenericName":"SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/1.5ML","NDC":"00169770421"},{"Id":387656,"FormularyType":"OHP","DrugName":"NORDITROPIN INJ 10/1.5ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000D230","GenericName":"SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/1.5ML","NDC":"00169770521"},{"Id":387657,"FormularyType":"OHP","DrugName":"NORDITROPIN INJ 15/1.5ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000D240","GenericName":"SOMATROPIN SOLUTION PEN-INJECTOR 15 MG/1.5ML","NDC":"00169770821"},{"Id":387658,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"00172208360"},{"Id":387659,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"00172208380"},{"Id":387660,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"00172208960"},{"Id":387661,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"00172208980"},{"Id":387662,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"00172344460"},{"Id":387663,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"00172344480"},{"Id":387664,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00172409660"},{"Id":387665,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00172409680"},{"Id":387666,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00172409760"},{"Id":387667,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00172409780"},{"Id":387668,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00172572860"},{"Id":387669,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00172572870"},{"Id":387670,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00172572880"},{"Id":387671,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"00172572960"},{"Id":387672,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"00172572970"},{"Id":387673,"FormularyType":"OHP","DrugName":"CYCLOSPORINE SOL MODIFIED","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020302020","GenericName":"CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML","NDC":"00172731320"},{"Id":387674,"FormularyType":"OHP","DrugName":"SEREVENT DIS AER 50MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201058108020","GenericName":"SALMETEROL XINAFOATE AER POW BA 50 MCG/ACT (BASE EQUIV)","NDC":"00173052100"},{"Id":387675,"FormularyType":"OHP","DrugName":"RELENZA MIS DISKHALE","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504080008020","GenericName":"ZANAMIVIR AEROSOL POWDER BREATH ACTIVATED 5 MG/ACT","NDC":"00173068101"},{"Id":387676,"FormularyType":"OHP","DrugName":"ADVAIR HFA AER 45/21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703250","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT","NDC":"00173071520"},{"Id":387677,"FormularyType":"OHP","DrugName":"ADVAIR HFA AER 45/21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703250","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT","NDC":"00173071522"},{"Id":387678,"FormularyType":"OHP","DrugName":"ADVAIR HFA AER 115/21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703260","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 115-21 MCG/ACT","NDC":"00173071620"},{"Id":387679,"FormularyType":"OHP","DrugName":"ADVAIR HFA AER 115/21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703260","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 115-21 MCG/ACT","NDC":"00173071622"},{"Id":387680,"FormularyType":"OHP","DrugName":"ADVAIR HFA AER 230/21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703270","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 230-21 MCG/ACT","NDC":"00173071720"},{"Id":387681,"FormularyType":"OHP","DrugName":"ADVAIR HFA AER 230/21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703270","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 230-21 MCG/ACT","NDC":"00173071722"},{"Id":387682,"FormularyType":"OHP","DrugName":"ANORO ELLIPT AER 62.5-25","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902958020","GenericName":"UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/ACT","NDC":"00173086906"},{"Id":387683,"FormularyType":"OHP","DrugName":"ANORO ELLIPT AER 62.5-25","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902958020","GenericName":"UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/ACT","NDC":"00173086910"},{"Id":387684,"FormularyType":"OHP","DrugName":"INCRUSE ELPT INH 62.5MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"62.5","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100090208030","GenericName":"UMECLIDINIUM BR AERO POWD BREATH ACT 62.5 MCG/ACT (BASE EQ)","NDC":"00173087306"},{"Id":387685,"FormularyType":"OHP","DrugName":"INCRUSE ELPT INH 62.5MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"62.5","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100090208030","GenericName":"UMECLIDINIUM BR AERO POWD BREATH ACT 62.5 MCG/ACT (BASE EQ)","NDC":"00173087310"},{"Id":387686,"FormularyType":"OHP","DrugName":"TRELEGY AER 100MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209903408020","GenericName":"FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 100-62.5-25 MCG/ACT","NDC":"00173088710"},{"Id":387687,"FormularyType":"OHP","DrugName":"TRELEGY AER 100MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209903408020","GenericName":"FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 100-62.5-25 MCG/ACT","NDC":"00173088714"},{"Id":387688,"FormularyType":"OHP","DrugName":"TRELEGY AER 100MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209903408020","GenericName":"FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 100-62.5-25 MCG/ACT","NDC":"00173088761"},{"Id":387689,"FormularyType":"OHP","DrugName":"KRINTAFEL TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000070200320","GenericName":"TAFENOQUINE SUCCINATE TAB 150 MG (BASE EQUIVALENT)","NDC":"00173088939"},{"Id":387690,"FormularyType":"OHP","DrugName":"NUCALA INJ 100MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460405500D530","GenericName":"MEPOLIZUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML","NDC":"00173089201"},{"Id":387691,"FormularyType":"OHP","DrugName":"NUCALA INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460405500E530","GenericName":"MEPOLIZUMAB SUBCUTANEOUS SOLUTION PREF SYRINGE 100 MG/ML","NDC":"00173089242"},{"Id":387692,"FormularyType":"OHP","DrugName":"NUCALA INJ 100MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460405500D530","GenericName":"MEPOLIZUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML","NDC":"00173089261"},{"Id":387693,"FormularyType":"OHP","DrugName":"TRELEGY AER 200MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209903408040","GenericName":"FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 200-62.5-25 MCG/ACT","NDC":"00173089310"},{"Id":387694,"FormularyType":"OHP","DrugName":"TRELEGY AER 200MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209903408040","GenericName":"FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 200-62.5-25 MCG/ACT","NDC":"00173089314"},{"Id":387695,"FormularyType":"OHP","DrugName":"TRELEGY AER 200MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209903408040","GenericName":"FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 200-62.5-25 MCG/ACT","NDC":"00173089361"},{"Id":387696,"FormularyType":"OHP","DrugName":"NUCALA INJ 40MG/0.4","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460405500E520","GenericName":"MEPOLIZUMAB SUBCUTANEOUS SOLUTION PREF SYRINGE 40 MG/0.4ML","NDC":"00173090442"},{"Id":387697,"FormularyType":"OHP","DrugName":"ZEJULA TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535550200330","GenericName":"NIRAPARIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"00173091213"},{"Id":387698,"FormularyType":"OHP","DrugName":"ZEJULA TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535550200340","GenericName":"NIRAPARIB TOSYLATE TAB 300 MG (BASE EQUIVALENT)","NDC":"00173091513"},{"Id":387699,"FormularyType":"OHP","DrugName":"KP ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00179801125"},{"Id":387700,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"00179802401"},{"Id":387701,"FormularyType":"OHP","DrugName":"KP NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"00179802902"},{"Id":387702,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"00179803501"},{"Id":387703,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"00179804912"},{"Id":387704,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"00179805002"},{"Id":387705,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000318","GenericName":"FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON)","NDC":"00179805301"},{"Id":387706,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00179805401"},{"Id":387707,"FormularyType":"OHP","DrugName":"CALC CITRA+D TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"00179805602"},{"Id":387708,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"00179805701"},{"Id":387709,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"00179805802"},{"Id":387710,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"00179806002"},{"Id":387711,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"00179806102"},{"Id":387712,"FormularyType":"OHP","DrugName":"KP BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00179815001"},{"Id":387713,"FormularyType":"OHP","DrugName":"KP SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00179815601"},{"Id":387714,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"00179830701"},{"Id":387715,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00179831301"},{"Id":387716,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100310","GenericName":"PSEUDOEPHEDRINE HCL TAB 60 MG","NDC":"00179831550"},{"Id":387717,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"00179832330"},{"Id":387718,"FormularyType":"OHP","DrugName":"VITAMIN D CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"00179840418"},{"Id":387719,"FormularyType":"OHP","DrugName":"KP B COMPLEX TAB /C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"00179840702"},{"Id":387720,"FormularyType":"OHP","DrugName":"KP CALCIUM TAB 600+D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"00179841302"},{"Id":387721,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000318","GenericName":"FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON)","NDC":"00179841701"},{"Id":387722,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00179841901"},{"Id":387723,"FormularyType":"OHP","DrugName":"KP FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"00179842118"},{"Id":387724,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"00179842302"},{"Id":387725,"FormularyType":"OHP","DrugName":"KP MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"00179842712"},{"Id":387726,"FormularyType":"OHP","DrugName":"KP PRENATAL TAB MULTIVIT","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"00179843990"},{"Id":387727,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"00179844502"},{"Id":387728,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"00185005501"},{"Id":387729,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"00185005510"},{"Id":387730,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"00185012201"},{"Id":387731,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"00185012210"},{"Id":387732,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"00185012801"},{"Id":387733,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"00185012805"},{"Id":387734,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"00185012901"},{"Id":387735,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"00185012905"},{"Id":387736,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"00185013001"},{"Id":387737,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"00185013005"},{"Id":387738,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150330","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"00185021101"},{"Id":387739,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150310","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"00185023601"},{"Id":387740,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150340","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"00185027701"},{"Id":387741,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150320","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"00185032501"},{"Id":387742,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00185067401"},{"Id":387743,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00185067405"},{"Id":387744,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"00185067601"},{"Id":387745,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"00185067605"},{"Id":387746,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"00185084201"},{"Id":387747,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"00185085301"},{"Id":387748,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"00185209801"},{"Id":387749,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"00185209901"},{"Id":387750,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"00185505001"},{"Id":387751,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"00185560001"},{"Id":387752,"FormularyType":"OHP","DrugName":"SILIQ INJ 210/1.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"210","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025052000E520","GenericName":"BRODALUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 210 MG/1.5ML","NDC":"00187000400"},{"Id":387753,"FormularyType":"OHP","DrugName":"SILIQ INJ 210/1.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"210","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025052000E520","GenericName":"BRODALUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 210 MG/1.5ML","NDC":"00187000402"},{"Id":387754,"FormularyType":"OHP","DrugName":"ENTERADE LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"00220099962"},{"Id":387755,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"00223172101"},{"Id":387756,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"00223172102"},{"Id":387757,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"00228212710"},{"Id":387758,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"00228212750"},{"Id":387759,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"00228212810"},{"Id":387760,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"00228212850"},{"Id":387761,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"00228212910"},{"Id":387762,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"00228255006"},{"Id":387763,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"00228255011"},{"Id":387764,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"00228255096"},{"Id":387765,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"00228255106"},{"Id":387766,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"00228255111"},{"Id":387767,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"00228255196"},{"Id":387768,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000305","GenericName":"INDAPAMIDE TAB 2.5 MG","NDC":"00228257111"},{"Id":387769,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000305","GenericName":"INDAPAMIDE TAB 2.5 MG","NDC":"00228257196"},{"Id":387770,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000303","GenericName":"INDAPAMIDE TAB 1.25 MG","NDC":"00228259711"},{"Id":387771,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000303","GenericName":"INDAPAMIDE TAB 1.25 MG","NDC":"00228259796"},{"Id":387772,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 60MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107025","GenericName":"PROPRANOLOL HCL CAP ER 24HR 60 MG","NDC":"00228277811"},{"Id":387773,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 80MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107030","GenericName":"PROPRANOLOL HCL CAP ER 24HR 80 MG","NDC":"00228277911"},{"Id":387774,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107035","GenericName":"PROPRANOLOL HCL CAP ER 24HR 120 MG","NDC":"00228278011"},{"Id":387775,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 160MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107040","GenericName":"PROPRANOLOL HCL CAP ER 24HR 160 MG","NDC":"00228278111"},{"Id":387776,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"00228280111"},{"Id":387777,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100320","GenericName":"PILOCARPINE HCL TAB 7.5 MG","NDC":"00228283711"},{"Id":387778,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"00228291809"},{"Id":387779,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"00228305911"},{"Id":387780,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"00228306011"},{"Id":387781,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"00228306111"},{"Id":387782,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"00228306211"},{"Id":387783,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"00228306311"},{"Id":387784,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"00228306411"},{"Id":387785,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"00228315303"},{"Id":387786,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"00228315403"},{"Id":387787,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"00228315503"},{"Id":387788,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"00228315603"},{"Id":387789,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"00228427111"},{"Id":387790,"FormularyType":"OHP","DrugName":"PREVALITE POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"00245003623"},{"Id":387791,"FormularyType":"OHP","DrugName":"PREVALITE POW 4GM PK","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"00245003642"},{"Id":387792,"FormularyType":"OHP","DrugName":"PREVALITE POW 4GM PK","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"00245003660"},{"Id":387793,"FormularyType":"OHP","DrugName":"PREVALITE POW 4GM PK","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"00245003689"},{"Id":387794,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"00245010801"},{"Id":387795,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"00245010810"},{"Id":387796,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"00245010811"},{"Id":387797,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"00245010889"},{"Id":387798,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"00245021111"},{"Id":387799,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"00245021201"},{"Id":387800,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"00245021211"},{"Id":387801,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"00245021289"},{"Id":387802,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"00245021311"},{"Id":387803,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00245057001"},{"Id":387804,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00245057089"},{"Id":387805,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00245057101"},{"Id":387806,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00245057189"},{"Id":387807,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00245057301"},{"Id":387808,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00245057389"},{"Id":387809,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00245057501"},{"Id":387810,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00245057589"},{"Id":387811,"FormularyType":"OHP","DrugName":"TORPENZ TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"00245082204"},{"Id":387812,"FormularyType":"OHP","DrugName":"TORPENZ TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"00245082230"},{"Id":387813,"FormularyType":"OHP","DrugName":"TORPENZ TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"00245082289"},{"Id":387814,"FormularyType":"OHP","DrugName":"TORPENZ TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"00245082304"},{"Id":387815,"FormularyType":"OHP","DrugName":"TORPENZ TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"00245082330"},{"Id":387816,"FormularyType":"OHP","DrugName":"TORPENZ TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"00245082389"},{"Id":387817,"FormularyType":"OHP","DrugName":"TORPENZ TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"00245082404"},{"Id":387818,"FormularyType":"OHP","DrugName":"TORPENZ TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"00245082430"},{"Id":387819,"FormularyType":"OHP","DrugName":"TORPENZ TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"00245082489"},{"Id":387820,"FormularyType":"OHP","DrugName":"TORPENZ TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"00245082504"},{"Id":387821,"FormularyType":"OHP","DrugName":"TORPENZ TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"00245082530"},{"Id":387822,"FormularyType":"OHP","DrugName":"TORPENZ TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"00245082589"},{"Id":387823,"FormularyType":"OHP","DrugName":"KLOR-CON 10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00245083601"},{"Id":387824,"FormularyType":"OHP","DrugName":"KLOR-CON 10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00245083611"},{"Id":387825,"FormularyType":"OHP","DrugName":"KLOR-CON 10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00245083615"},{"Id":387826,"FormularyType":"OHP","DrugName":"KLOR-CON 10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00245083689"},{"Id":387827,"FormularyType":"OHP","DrugName":"KLOR-CON 8 TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"00245531501"},{"Id":387828,"FormularyType":"OHP","DrugName":"KLOR-CON 8 TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"00245531511"},{"Id":387829,"FormularyType":"OHP","DrugName":"KLOR-CON 8 TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"00245531515"},{"Id":387830,"FormularyType":"OHP","DrugName":"KLOR-CON 8 TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"00245531589"},{"Id":387831,"FormularyType":"OHP","DrugName":"KLOR-CON M10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00245531701"},{"Id":387832,"FormularyType":"OHP","DrugName":"KLOR-CON M10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00245531710"},{"Id":387833,"FormularyType":"OHP","DrugName":"KLOR-CON M10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00245531711"},{"Id":387834,"FormularyType":"OHP","DrugName":"KLOR-CON M10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00245531789"},{"Id":387835,"FormularyType":"OHP","DrugName":"KLOR-CON M10 TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00245531790"},{"Id":387836,"FormularyType":"OHP","DrugName":"KLOR-CON M20 TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00245531901"},{"Id":387837,"FormularyType":"OHP","DrugName":"KLOR-CON M20 TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00245531910"},{"Id":387838,"FormularyType":"OHP","DrugName":"KLOR-CON M20 TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00245531911"},{"Id":387839,"FormularyType":"OHP","DrugName":"KLOR-CON M20 TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00245531915"},{"Id":387840,"FormularyType":"OHP","DrugName":"KLOR-CON M20 TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00245531989"},{"Id":387841,"FormularyType":"OHP","DrugName":"KLOR-CON M20 TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00245531990"},{"Id":387842,"FormularyType":"OHP","DrugName":"DIAZOXIDE SUS 50MG/ML","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300020001810","GenericName":"DIAZOXIDE SUSP 50 MG/ML","NDC":"00254101019"},{"Id":387843,"FormularyType":"OHP","DrugName":"POSACONAZOLE SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060001820","GenericName":"POSACONAZOLE SUSP 40 MG/ML","NDC":"00254101636"},{"Id":387844,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000320","GenericName":"CHLORZOXAZONE TAB 750 MG","NDC":"00254200501"},{"Id":387845,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"00254200801"},{"Id":387846,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"00254200811"},{"Id":387847,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"00254204502"},{"Id":387848,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000307","GenericName":"CHLORZOXAZONE TAB 375 MG","NDC":"00254205301"},{"Id":387849,"FormularyType":"OHP","DrugName":"NU-IRON 150 CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"00259029101"},{"Id":387850,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00264151031"},{"Id":387851,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00264151032"},{"Id":387852,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264180031"},{"Id":387853,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264180032"},{"Id":387854,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264180036"},{"Id":387855,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00264194420"},{"Id":387856,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00264210100"},{"Id":387857,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00264210110"},{"Id":387858,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00264220100"},{"Id":387859,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00264220110"},{"Id":387860,"FormularyType":"OHP","DrugName":"CEFAZOL/DEX SOL 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015132120","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 1 GM AND DEXTROSE 4% (50 ML)","NDC":"00264310311"},{"Id":387861,"FormularyType":"OHP","DrugName":"CEFAZOL/DEX SOL 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015132130","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 2 GM AND DEXTROSE 3% (50 ML)","NDC":"00264310511"},{"Id":387862,"FormularyType":"OHP","DrugName":"CEFAZOL/DEX SOL 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015132140","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 3 GM AND DEXTROSE 2% (50 ML)","NDC":"00264310711"},{"Id":387863,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060142110","GenericName":"CEFOXITIN SODIUM IV FOR SOLN 1 GM AND DEXTROSE 4% (50 ML)","NDC":"00264312311"},{"Id":387864,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060142120","GenericName":"CEFOXITIN SODIUM IV FOR SOLN 2 GM AND DEXTROSE 2.2% (50 ML)","NDC":"00264312511"},{"Id":387865,"FormularyType":"OHP","DrugName":"CEFTRIAX/DEX INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090132120","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 1 GM AND DEXTROSE 3.74% 50 ML","NDC":"00264315311"},{"Id":387866,"FormularyType":"OHP","DrugName":"CEFTRIAX/DEX INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090132130","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 2 GM AND DEXTROSE 2.22% 50 ML","NDC":"00264315511"},{"Id":387867,"FormularyType":"OHP","DrugName":"MEROP/NACL INJ 500/50ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050052120","GenericName":"MEROPENEM & SODIUM CHLORIDE 0.9% FOR IV SOLN 500 MG/50ML","NDC":"00264318311"},{"Id":387868,"FormularyType":"OHP","DrugName":"MEROP/NACL INJ 1GM/50ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050052130","GenericName":"MEROPENEM & SODIUM CHLORIDE 0.9% FOR IV SOLN 1 GM/50ML","NDC":"00264318511"},{"Id":387869,"FormularyType":"OHP","DrugName":"CEFEPIME/DEX INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040122110","GenericName":"CEFEPIME HCL FOR IV SOLN 1 GM AND DEXTROSE 5% (50 ML)","NDC":"00264319311"},{"Id":387870,"FormularyType":"OHP","DrugName":"CEFEPIME/DEX INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040122120","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM AND DEXTROSE 5% (50 ML)","NDC":"00264319511"},{"Id":387871,"FormularyType":"OHP","DrugName":"PIP/TAZ/NACL INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002732110","GenericName":"PIPERACILLIN-TAZOBACTAM &NACL 0.45% FOR IV SOL 2-0.25GM/50ML","NDC":"00264344611"},{"Id":387872,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"00264553532"},{"Id":387873,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264580200"},{"Id":387874,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264580210"},{"Id":387875,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00264580400"},{"Id":387876,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00264738550"},{"Id":387877,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00264738560"},{"Id":387878,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00264738650"},{"Id":387879,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00264738660"},{"Id":387880,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002060","GenericName":"DEXTROSE INJ 70%","NDC":"00264738750"},{"Id":387881,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00264738850"},{"Id":387882,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00264738860"},{"Id":387883,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00264751000"},{"Id":387884,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00264751010"},{"Id":387885,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00264751020"},{"Id":387886,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00264752000"},{"Id":387887,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00264752010"},{"Id":387888,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00264752020"},{"Id":387889,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00264761000"},{"Id":387890,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00264761010"},{"Id":387891,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00264761200"},{"Id":387892,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00264761210"},{"Id":387893,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264780000"},{"Id":387894,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264780009"},{"Id":387895,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264780010"},{"Id":387896,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00264780020"},{"Id":387897,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00264780200"},{"Id":387898,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00264780210"},{"Id":387899,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 3%","DosageForm":"SOLN - Solution","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002030","GenericName":"SODIUM CHLORIDE IV SOLN 3%","NDC":"00264780510"},{"Id":387900,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002040","GenericName":"SODIUM CHLORIDE IV SOLN 5%","NDC":"00264780610"},{"Id":387901,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00264785000"},{"Id":387902,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00264785010"},{"Id":387903,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00264785020"},{"Id":387904,"FormularyType":"OHP","DrugName":"KETOPROFEN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100035000103","GenericName":"KETOPROFEN CAP 25 MG","NDC":"00276050410"},{"Id":387905,"FormularyType":"OHP","DrugName":"KETOPROFEN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"M","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100035000105","GenericName":"KETOPROFEN CAP 50 MG","NDC":"00276050610"},{"Id":387906,"FormularyType":"OHP","DrugName":"BAYER ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00280200024"},{"Id":387907,"FormularyType":"OHP","DrugName":"BAYER LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00280208036"},{"Id":387908,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00280210040"},{"Id":387909,"FormularyType":"OHP","DrugName":"BAYER ASPIRI TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"00280211010"},{"Id":387910,"FormularyType":"OHP","DrugName":"NITRO-BID OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030004205","GenericName":"NITROGLYCERIN OINT 2%","NDC":"00281032608"},{"Id":387911,"FormularyType":"OHP","DrugName":"NITRO-BID OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030004205","GenericName":"NITROGLYCERIN OINT 2%","NDC":"00281032630"},{"Id":387912,"FormularyType":"OHP","DrugName":"NITRO-BID OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030004205","GenericName":"NITROGLYCERIN OINT 2%","NDC":"00281032660"},{"Id":387913,"FormularyType":"OHP","DrugName":"DIFFERIN GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"00299492030"},{"Id":387914,"FormularyType":"OHP","DrugName":"DIFFERIN GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"00299492045"},{"Id":387915,"FormularyType":"OHP","DrugName":"NEMLUVIO INJ 30MG","DosageForm":"AUIJ - Auto-Injector","Strength":"30","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - SYSTEMIC","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9079355510D420","GenericName":"NEMOLIZUMAB-ILTO FOR SUBCUTANEOUS AUTO-INJECTOR 30 MG","NDC":"00299622010"},{"Id":387916,"FormularyType":"OHP","DrugName":"NEMLUVIO INJ 30MG","DosageForm":"AUIJ - Auto-Injector","Strength":"30","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - SYSTEMIC","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9079355510D420","GenericName":"NEMOLIZUMAB-ILTO FOR SUBCUTANEOUS AUTO-INJECTOR 30 MG","NDC":"00299622015"},{"Id":387917,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000330","GenericName":"OLAPARIB TAB 100 MG","NDC":"00310056912"},{"Id":387918,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000330","GenericName":"OLAPARIB TAB 100 MG","NDC":"00310056960"},{"Id":387919,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000340","GenericName":"OLAPARIB TAB 150 MG","NDC":"00310057812"},{"Id":387920,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000340","GenericName":"OLAPARIB TAB 150 MG","NDC":"00310057860"},{"Id":387921,"FormularyType":"OHP","DrugName":"KOSELUGO CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533565500110","GenericName":"SELUMETINIB SULFATE CAP 10 MG","NDC":"00310061028"},{"Id":387922,"FormularyType":"OHP","DrugName":"KOSELUGO CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533565500110","GenericName":"SELUMETINIB SULFATE CAP 10 MG","NDC":"00310061060"},{"Id":387923,"FormularyType":"OHP","DrugName":"KOSELUGO CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533565500125","GenericName":"SELUMETINIB SULFATE CAP 25 MG","NDC":"00310062528"},{"Id":387924,"FormularyType":"OHP","DrugName":"KOSELUGO CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533565500125","GenericName":"SELUMETINIB SULFATE CAP 25 MG","NDC":"00310062560"},{"Id":387925,"FormularyType":"OHP","DrugName":"KOSELUGO CAP 5MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533565506810","GenericName":"SELUMETINIB SULFATE CAP SPRINKLE 5 MG","NDC":"00310063560"},{"Id":387926,"FormularyType":"OHP","DrugName":"KOSELUGO CAP 7.5MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"7.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533565506815","GenericName":"SELUMETINIB SULFATE CAP SPRINKLE 7.5 MG","NDC":"00310064060"},{"Id":387927,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000330","GenericName":"OLAPARIB TAB 100 MG","NDC":"00310066812"},{"Id":387928,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000330","GenericName":"OLAPARIB TAB 100 MG","NDC":"00310066860"},{"Id":387929,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000340","GenericName":"OLAPARIB TAB 150 MG","NDC":"00310067912"},{"Id":387930,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000340","GenericName":"OLAPARIB TAB 150 MG","NDC":"00310067960"},{"Id":387931,"FormularyType":"OHP","DrugName":"LYNPARZA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535560000340","GenericName":"OLAPARIB TAB 150 MG","NDC":"00310067995"},{"Id":387932,"FormularyType":"OHP","DrugName":"LOKELMA PAK 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450020003020","GenericName":"SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 5 GM","NDC":"00310110501"},{"Id":387933,"FormularyType":"OHP","DrugName":"LOKELMA PAK 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450020003020","GenericName":"SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 5 GM","NDC":"00310110530"},{"Id":387934,"FormularyType":"OHP","DrugName":"LOKELMA PAK 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450020003020","GenericName":"SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 5 GM","NDC":"00310110539"},{"Id":387935,"FormularyType":"OHP","DrugName":"LOKELMA PAK 10GM","DosageForm":"PACK - Packet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450020003040","GenericName":"SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 10 GM","NDC":"00310111001"},{"Id":387936,"FormularyType":"OHP","DrugName":"LOKELMA PAK 10GM","DosageForm":"PACK - Packet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450020003040","GenericName":"SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 10 GM","NDC":"00310111030"},{"Id":387937,"FormularyType":"OHP","DrugName":"LOKELMA PAK 10GM","DosageForm":"PACK - Packet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450020003040","GenericName":"SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 10 GM","NDC":"00310111039"},{"Id":387938,"FormularyType":"OHP","DrugName":"TAGRISSO TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360068200320","GenericName":"OSIMERTINIB MESYLATE TAB 40 MG (BASE EQUIVALENT)","NDC":"00310124830"},{"Id":387939,"FormularyType":"OHP","DrugName":"TAGRISSO TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360068200330","GenericName":"OSIMERTINIB MESYLATE TAB 80 MG (BASE EQUIVALENT)","NDC":"00310125130"},{"Id":387940,"FormularyType":"OHP","DrugName":"TAGRISSO TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360068200320","GenericName":"OSIMERTINIB MESYLATE TAB 40 MG (BASE EQUIVALENT)","NDC":"00310134930"},{"Id":387941,"FormularyType":"OHP","DrugName":"TAGRISSO TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360068200330","GenericName":"OSIMERTINIB MESYLATE TAB 80 MG (BASE EQUIVALENT)","NDC":"00310135030"},{"Id":387942,"FormularyType":"OHP","DrugName":"FASENRA INJ 10MG/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460402000E515","GenericName":"BENRALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 10 MG/0.5ML","NDC":"00310174501"},{"Id":387943,"FormularyType":"OHP","DrugName":"FASENRA INJ 10MG/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460402000E515","GenericName":"BENRALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 10 MG/0.5ML","NDC":"00310174595"},{"Id":387944,"FormularyType":"OHP","DrugName":"FASENRA PEN INJ 30MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460402000D520","GenericName":"BENRALIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 30 MG/ML","NDC":"00310183030"},{"Id":387945,"FormularyType":"OHP","DrugName":"FASENRA PEN INJ 30MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460402000D520","GenericName":"BENRALIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 30 MG/ML","NDC":"00310183085"},{"Id":387946,"FormularyType":"OHP","DrugName":"CALQUENCE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532103500320","GenericName":"ACALABRUTINIB MALEATE TAB 100 MG","NDC":"00310351260"},{"Id":387947,"FormularyType":"OHP","DrugName":"CALQUENCE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532103500320","GenericName":"ACALABRUTINIB MALEATE TAB 100 MG","NDC":"00310451360"},{"Id":387948,"FormularyType":"OHP","DrugName":"FARXIGA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200310","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG (BASE EQUIVALENT)","NDC":"00310620530"},{"Id":387949,"FormularyType":"OHP","DrugName":"FARXIGA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200310","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG (BASE EQUIVALENT)","NDC":"00310620590"},{"Id":387950,"FormularyType":"OHP","DrugName":"FARXIGA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200310","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG (BASE EQUIVALENT)","NDC":"00310620595"},{"Id":387951,"FormularyType":"OHP","DrugName":"FARXIGA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200320","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 10 MG (BASE EQUIVALENT)","NDC":"00310621030"},{"Id":387952,"FormularyType":"OHP","DrugName":"FARXIGA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200320","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 10 MG (BASE EQUIVALENT)","NDC":"00310621039"},{"Id":387953,"FormularyType":"OHP","DrugName":"FARXIGA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200320","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 10 MG (BASE EQUIVALENT)","NDC":"00310621090"},{"Id":387954,"FormularyType":"OHP","DrugName":"FARXIGA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200320","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 10 MG (BASE EQUIVALENT)","NDC":"00310621095"},{"Id":387955,"FormularyType":"OHP","DrugName":"XIGDUO XR TAB 2.5-1000","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307507","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 2.5-1000 MG","NDC":"00310622560"},{"Id":387956,"FormularyType":"OHP","DrugName":"XIGDUO XR TAB 5-500MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307510","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 5-500 MG","NDC":"00310625030"},{"Id":387957,"FormularyType":"OHP","DrugName":"XIGDUO XR TAB 5-1000MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307515","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 5-1000 MG","NDC":"00310626060"},{"Id":387958,"FormularyType":"OHP","DrugName":"XIGDUO XR TAB 10-500MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307520","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 10-500 MG","NDC":"00310627030"},{"Id":387959,"FormularyType":"OHP","DrugName":"XIGDUO XR TAB 10-1000","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307525","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 10-1000 MG","NDC":"00310628030"},{"Id":387960,"FormularyType":"OHP","DrugName":"BUDES/FORMOT AER 160-4.5","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902413240","GenericName":"BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 160-4.5 MCG/ACT","NDC":"00310737020"},{"Id":387961,"FormularyType":"OHP","DrugName":"BUDES/FORMOT AER 80-4.5","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902413220","GenericName":"BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT","NDC":"00310737220"},{"Id":387962,"FormularyType":"OHP","DrugName":"TRUQAP TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530320000325","GenericName":"CAPIVASERTIB TAB 200 MG","NDC":"00310950101"},{"Id":387963,"FormularyType":"OHP","DrugName":"ALA-CORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00316012601"},{"Id":387964,"FormularyType":"OHP","DrugName":"TRIDERM CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103720","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.5%","NDC":"00316017516"},{"Id":387965,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00316018601"},{"Id":387966,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00316018616"},{"Id":387967,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"00316019316"},{"Id":387968,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"00316019320"},{"Id":387969,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"00316019330"},{"Id":387970,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"00316022115"},{"Id":387971,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"00316022130"},{"Id":387972,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"00316022315"},{"Id":387973,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"00316022330"},{"Id":387974,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"00316022360"},{"Id":387975,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00338000344"},{"Id":387976,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00338000346"},{"Id":387977,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00338000347"},{"Id":387978,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00338000402"},{"Id":387979,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00338000403"},{"Id":387980,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00338000404"},{"Id":387981,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00338001304"},{"Id":387982,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00338001306"},{"Id":387983,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00338001308"},{"Id":387984,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00338001329"},{"Id":387985,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001702"},{"Id":387986,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001703"},{"Id":387987,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001704"},{"Id":387988,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001710"},{"Id":387989,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001711"},{"Id":387990,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001718"},{"Id":387991,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001731"},{"Id":387992,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001738"},{"Id":387993,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001741"},{"Id":387994,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338001748"},{"Id":387995,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00338002302"},{"Id":387996,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00338002303"},{"Id":387997,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00338002304"},{"Id":387998,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00338004303"},{"Id":387999,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00338004304"},{"Id":388000,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004727"},{"Id":388001,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004729"},{"Id":388002,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004744"},{"Id":388003,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004746"},{"Id":388004,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004747"},{"Id":388005,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004802"},{"Id":388006,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004803"},{"Id":388007,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338004804"},{"Id":388008,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004902"},{"Id":388009,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004903"},{"Id":388010,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004904"},{"Id":388011,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004910"},{"Id":388012,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004911"},{"Id":388013,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004918"},{"Id":388014,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004931"},{"Id":388015,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004938"},{"Id":388016,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004941"},{"Id":388017,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338004948"},{"Id":388018,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338005047"},{"Id":388019,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338005144"},{"Id":388020,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 3%","DosageForm":"SOLN - Solution","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002030","GenericName":"SODIUM CHLORIDE IV SOLN 3%","NDC":"00338005403"},{"Id":388021,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002040","GenericName":"SODIUM CHLORIDE IV SOLN 5%","NDC":"00338005603"},{"Id":388022,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338006230"},{"Id":388023,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338006620"},{"Id":388024,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338007010"},{"Id":388025,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00338008503"},{"Id":388026,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00338008504"},{"Id":388027,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00338008903"},{"Id":388028,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00338008904"},{"Id":388029,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ DEXTROSE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015132060","GenericName":"CEFAZOLIN SODIUM-DEXTROSE IV SOLUTION 3 GM/150ML-4%","NDC":"00338009606"},{"Id":388030,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338011001"},{"Id":388031,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00338011004"},{"Id":388032,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122055","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1.25 GM/250ML-5%","NDC":"00338012204"},{"Id":388033,"FormularyType":"OHP","DrugName":"GENTAM/NACL INJ 80MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020112008","GenericName":"GENTAMICIN IN SALINE INJ 0.8 MG/ML","NDC":"00338050348"},{"Id":388034,"FormularyType":"OHP","DrugName":"GENTAM/NACL INJ 100MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020112015","GenericName":"GENTAMICIN IN SALINE INJ 1 MG/ML","NDC":"00338050548"},{"Id":388035,"FormularyType":"OHP","DrugName":"GENTAM/NACL INJ 60MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020112025","GenericName":"GENTAMICIN IN SALINE INJ 1.2 MG/ML","NDC":"00338050741"},{"Id":388036,"FormularyType":"OHP","DrugName":"GENTAM/NACL INJ 120MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020112025","GenericName":"GENTAMICIN IN SALINE INJ 1.2 MG/ML","NDC":"00338050748"},{"Id":388037,"FormularyType":"OHP","DrugName":"GENTAM/NACL INJ 80MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020112045","GenericName":"GENTAMICIN IN SALINE INJ 1.6 MG/ML","NDC":"00338050941"},{"Id":388038,"FormularyType":"OHP","DrugName":"GENTAM/NACL INJ 100MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020112065","GenericName":"GENTAMICIN IN SALINE INJ 2 MG/ML","NDC":"00338051141"},{"Id":388039,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338055111"},{"Id":388040,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338055118"},{"Id":388041,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338055311"},{"Id":388042,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338055318"},{"Id":388043,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002070","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/50ML","NDC":"00338070341"},{"Id":388044,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 40MEQ","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002075","GenericName":"POTASSIUM CHLORIDE INJ 40 MEQ/100ML","NDC":"00338070348"},{"Id":388045,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002055","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/50ML","NDC":"00338070541"},{"Id":388046,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002060","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/100ML","NDC":"00338070548"},{"Id":388047,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002050","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/100ML","NDC":"00338070948"},{"Id":388048,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002060","GenericName":"DEXTROSE INJ 70%","NDC":"00338071906"},{"Id":388049,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 2GM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050112030","GenericName":"OXACILLIN SODIUM IN DEXTROSE INJ 2 GM/50ML","NDC":"00338101541"},{"Id":388050,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM/100","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040112025","GenericName":"NAFCILLIN SODIUM IN DEXTROSE INJ 2 GM/100ML","NDC":"00338101948"},{"Id":388051,"FormularyType":"OHP","DrugName":"PEN GK/DEXTR INJ 40000/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010112060","GenericName":"PENICILLIN G POTASSIUM INJ 40000 UNIT/ML IN DEXTROSE","NDC":"00338102341"},{"Id":388052,"FormularyType":"OHP","DrugName":"PEN GK/DEXTR INJ 60000/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010112070","GenericName":"PENICILLIN G POTASSIUM INJ 60000 UNIT/ML IN DEXTROSE","NDC":"00338102541"},{"Id":388053,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"00338105548"},{"Id":388054,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102022","GenericName":"CEFEPIME HCL IV SOLN 1 GM/50ML","NDC":"00338130141"},{"Id":388055,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2G/100ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102024","GenericName":"CEFEPIME HCL IV SOLN 2 GM/100ML","NDC":"00338130148"},{"Id":388056,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 300MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312020","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 300 MG/50ML","NDC":"00338341024"},{"Id":388057,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 300MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312020","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 300 MG/50ML","NDC":"00338341050"},{"Id":388058,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015132010","GenericName":"CEFAZOLIN SODIUM-DEXTROSE IV SOLUTION 1 GM/50ML-4%","NDC":"00338350341"},{"Id":388059,"FormularyType":"OHP","DrugName":"CEFAZOLIN SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015132030","GenericName":"CEFAZOLIN SODIUM-DEXTROSE IV SOLUTION 2 GM/100ML-4%","NDC":"00338350841"},{"Id":388060,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 500MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122020","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 500 MG/100ML-5%","NDC":"00338355148"},{"Id":388061,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1GM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122040","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1 GM/200ML-5%","NDC":"00338355248"},{"Id":388062,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 750MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122030","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 750 MG/150ML-5%","NDC":"00338358048"},{"Id":388063,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142020","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 500 MG/100ML-0.9%","NDC":"00338358101"},{"Id":388064,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142024","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 750 MG/150ML-0.9%","NDC":"00338358201"},{"Id":388065,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142036","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/200ML-0.9%","NDC":"00338358301"},{"Id":388066,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00338361224"},{"Id":388067,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00338361250"},{"Id":388068,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 600MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00338361624"},{"Id":388069,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 600MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00338361650"},{"Id":388070,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00338381424"},{"Id":388071,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00338381450"},{"Id":388072,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00338411424"},{"Id":388073,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00338411450"},{"Id":388074,"FormularyType":"OHP","DrugName":"CEFTRIAXONE/ INJ DEX 1GM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090112015","GenericName":"CEFTRIAXONE SODIUM IN DEXTROSE INJ 20 MG/ML","NDC":"00338500241"},{"Id":388075,"FormularyType":"OHP","DrugName":"CEFTRIAXONE/ INJ DEX 2GM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090112020","GenericName":"CEFTRIAXONE SODIUM IN DEXTROSE INJ 40 MG/ML","NDC":"00338500341"},{"Id":388076,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"00338604537"},{"Id":388077,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"00338604648"},{"Id":388078,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338914330"},{"Id":388079,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338914730"},{"Id":388080,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338915130"},{"Id":388081,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338915930"},{"Id":388082,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"00338954124"},{"Id":388083,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338954302"},{"Id":388084,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338954303"},{"Id":388085,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338954304"},{"Id":388086,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338954305"},{"Id":388087,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338954306"},{"Id":388088,"FormularyType":"OHP","DrugName":"CLINDMYC/NAC INJ 300/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020322010","GenericName":"CLINDAMYCIN PHOSPHATE IN NACL 0.9% IV SOLN 300 MG/50ML","NDC":"00338954524"},{"Id":388089,"FormularyType":"OHP","DrugName":"CLINDMYC/NAC INJ 300/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020322010","GenericName":"CLINDAMYCIN PHOSPHATE IN NACL 0.9% IV SOLN 300 MG/50ML","NDC":"00338954550"},{"Id":388090,"FormularyType":"OHP","DrugName":"CLINDMYC/NAC INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020322015","GenericName":"CLINDAMYCIN PHOSPHATE IN NACL 0.9% IV SOLN 600 MG/50ML","NDC":"00338954924"},{"Id":388091,"FormularyType":"OHP","DrugName":"CLINDMYC/NAC INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020322015","GenericName":"CLINDAMYCIN PHOSPHATE IN NACL 0.9% IV SOLN 600 MG/50ML","NDC":"00338954950"},{"Id":388092,"FormularyType":"OHP","DrugName":"CLINDMYC/NAC INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020322020","GenericName":"CLINDAMYCIN PHOSPHATE IN NACL 0.9% IV SOLN 900 MG/50ML","NDC":"00338955324"},{"Id":388093,"FormularyType":"OHP","DrugName":"CLINDMYC/NAC INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020322020","GenericName":"CLINDAMYCIN PHOSPHATE IN NACL 0.9% IV SOLN 900 MG/50ML","NDC":"00338955350"},{"Id":388094,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338964975"},{"Id":388095,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338965360"},{"Id":388096,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338965775"},{"Id":388097,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338966040"},{"Id":388098,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338966160"},{"Id":388099,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338966235"},{"Id":388100,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338966440"},{"Id":388101,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00338966635"},{"Id":388102,"FormularyType":"OHP","DrugName":"GLUCOSE 50% INJ DEXTROSE","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"00338978701"},{"Id":388103,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338979101"},{"Id":388104,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338979140"},{"Id":388105,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338979301"},{"Id":388106,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338979312"},{"Id":388107,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00338979901"},{"Id":388108,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00338979912"},{"Id":388109,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338980401"},{"Id":388110,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338980440"},{"Id":388111,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338980801"},{"Id":388112,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00338980824"},{"Id":388113,"FormularyType":"OHP","DrugName":"PEDIATRIC ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105110","GenericName":"*SODIUM PHOSPHATES - ENEMA (PEDIATRIC)***","NDC":"00363000142"},{"Id":388114,"FormularyType":"OHP","DrugName":"EASY-LAX PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363000220"},{"Id":388115,"FormularyType":"OHP","DrugName":"EASY-LAX PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363000260"},{"Id":388116,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE -TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00363000511"},{"Id":388117,"FormularyType":"OHP","DrugName":"LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"00363000518"},{"Id":388118,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE -TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00363000536"},{"Id":388119,"FormularyType":"OHP","DrugName":"PEDIATRIC ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105110","GenericName":"*SODIUM PHOSPHATES - ENEMA (PEDIATRIC)***","NDC":"00363000540"},{"Id":388120,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE -TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"00363000611"},{"Id":388121,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"00363000905"},{"Id":388122,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"00363000920"},{"Id":388123,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363001830"},{"Id":388124,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"00363002239"},{"Id":388125,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"00363002265"},{"Id":388126,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"00363002271"},{"Id":388127,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"00363002272"},{"Id":388128,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"00363002405"},{"Id":388129,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363003814"},{"Id":388130,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363003820"},{"Id":388131,"FormularyType":"OHP","DrugName":"WAL-SLEEP Z CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"00363006048"},{"Id":388132,"FormularyType":"OHP","DrugName":"WAL-PHED D TAB 120MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00363006160"},{"Id":388133,"FormularyType":"OHP","DrugName":"ANTACID LIQ SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363007302"},{"Id":388134,"FormularyType":"OHP","DrugName":"ANTACID LIQ SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363007326"},{"Id":388135,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363007405"},{"Id":388136,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"00363007564"},{"Id":388137,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"00363008001"},{"Id":388138,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"00363008002"},{"Id":388139,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"00363008100"},{"Id":388140,"FormularyType":"OHP","DrugName":"WAL-ITIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00363008501"},{"Id":388141,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363008802"},{"Id":388142,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363008808"},{"Id":388143,"FormularyType":"OHP","DrugName":"WAL-ITIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00363008816"},{"Id":388144,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00363009208"},{"Id":388145,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00363010065"},{"Id":388146,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00363010104"},{"Id":388147,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363010301"},{"Id":388148,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363010302"},{"Id":388149,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363010608"},{"Id":388150,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00363010612"},{"Id":388151,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00363010706"},{"Id":388152,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00363010708"},{"Id":388153,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00363010722"},{"Id":388154,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00363010901"},{"Id":388155,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00363010908"},{"Id":388156,"FormularyType":"OHP","DrugName":"WAL-MUCIL CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"00363011916"},{"Id":388157,"FormularyType":"OHP","DrugName":"WAL-MUCIL CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"00363011932"},{"Id":388158,"FormularyType":"OHP","DrugName":"FIBER-LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"00363012014"},{"Id":388159,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363012020"},{"Id":388160,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363012140"},{"Id":388161,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363012280"},{"Id":388162,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363012318"},{"Id":388163,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363012330"},{"Id":388164,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363012405"},{"Id":388165,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363012410"},{"Id":388166,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363013040"},{"Id":388167,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363013220"},{"Id":388168,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363013280"},{"Id":388169,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00363013338"},{"Id":388170,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363013810"},{"Id":388171,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363013820"},{"Id":388172,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363013830"},{"Id":388173,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363013850"},{"Id":388174,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363014101"},{"Id":388175,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00363015712"},{"Id":388176,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00363015714"},{"Id":388177,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00363015716"},{"Id":388178,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00363015798"},{"Id":388179,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363016002"},{"Id":388180,"FormularyType":"OHP","DrugName":"SENNA S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363016012"},{"Id":388181,"FormularyType":"OHP","DrugName":"SENNA S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363016022"},{"Id":388182,"FormularyType":"OHP","DrugName":"SENNA S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363016060"},{"Id":388183,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363016110"},{"Id":388184,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363016116"},{"Id":388185,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363016204"},{"Id":388186,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00363016626"},{"Id":388187,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363016704"},{"Id":388188,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363017508"},{"Id":388189,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363017514"},{"Id":388190,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363017526"},{"Id":388191,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363017534"},{"Id":388192,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363017537"},{"Id":388193,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363017801"},{"Id":388194,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00363017934"},{"Id":388195,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00363017956"},{"Id":388196,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363018100"},{"Id":388197,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00363018422"},{"Id":388198,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"00363018601"},{"Id":388199,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00363019007"},{"Id":388200,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00363019008"},{"Id":388201,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00363019401"},{"Id":388202,"FormularyType":"OHP","DrugName":"WAL-FINATE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"00363019415"},{"Id":388203,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00363019471"},{"Id":388204,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00363019816"},{"Id":388205,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363020105"},{"Id":388206,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363020176"},{"Id":388207,"FormularyType":"OHP","DrugName":"WAL-PHED D TAB 120MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00363020420"},{"Id":388208,"FormularyType":"OHP","DrugName":"WAL-PHED TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00363020421"},{"Id":388209,"FormularyType":"OHP","DrugName":"WAL-PHED TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00363020469"},{"Id":388210,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00363020501"},{"Id":388211,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% PLUS","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00363020632"},{"Id":388212,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00363020765"},{"Id":388213,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00363020772"},{"Id":388214,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00363020775"},{"Id":388215,"FormularyType":"OHP","DrugName":"ALLRGY RELF TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"00363021218"},{"Id":388216,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00363021874"},{"Id":388217,"FormularyType":"OHP","DrugName":"ASPIRIN-81 CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00363021879"},{"Id":388218,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"00363022434"},{"Id":388219,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"00363022757"},{"Id":388220,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"00363023064"},{"Id":388221,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 160MG JR","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00363023908"},{"Id":388222,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"00363025510"},{"Id":388223,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363025514"},{"Id":388224,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363025517"},{"Id":388225,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363025527"},{"Id":388226,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363025532"},{"Id":388227,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363027634"},{"Id":388228,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363028404"},{"Id":388229,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029114"},{"Id":388230,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029117"},{"Id":388231,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029137"},{"Id":388232,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029158"},{"Id":388233,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029208"},{"Id":388234,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029215"},{"Id":388235,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363029258"},{"Id":388236,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"00363029327"},{"Id":388237,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"00363029908"},{"Id":388238,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"00363029912"},{"Id":388239,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00363030602"},{"Id":388240,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00363030603"},{"Id":388241,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"00363031152"},{"Id":388242,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"00363031165"},{"Id":388243,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"00363031734"},{"Id":388244,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"00363031801"},{"Id":388245,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00363032706"},{"Id":388246,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00363032712"},{"Id":388247,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00363032756"},{"Id":388248,"FormularyType":"OHP","DrugName":"WAL-DRYL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00363032907"},{"Id":388249,"FormularyType":"OHP","DrugName":"WAL-DRYL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00363032978"},{"Id":388250,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363033016"},{"Id":388251,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363033144"},{"Id":388252,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00363033235"},{"Id":388253,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00363033240"},{"Id":388254,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033301"},{"Id":388255,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033304"},{"Id":388256,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033323"},{"Id":388257,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033350"},{"Id":388258,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033355"},{"Id":388259,"FormularyType":"OHP","DrugName":"HEADACHE REL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00363033412"},{"Id":388260,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033422"},{"Id":388261,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363033444"},{"Id":388262,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00363033550"},{"Id":388263,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033601"},{"Id":388264,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363033602"},{"Id":388265,"FormularyType":"OHP","DrugName":"ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"00363033631"},{"Id":388266,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00363033950"},{"Id":388267,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363034044"},{"Id":388268,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00363034050"},{"Id":388269,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00363034356"},{"Id":388270,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363034408"},{"Id":388271,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363034410"},{"Id":388272,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363034423"},{"Id":388273,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363034444"},{"Id":388274,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363034467"},{"Id":388275,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363034544"},{"Id":388276,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363035260"},{"Id":388277,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363035278"},{"Id":388278,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363036578"},{"Id":388279,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"00363036638"},{"Id":388280,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"00363036707"},{"Id":388281,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"00363036708"},{"Id":388282,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"00363036712"},{"Id":388283,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"00363036722"},{"Id":388284,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00363037478"},{"Id":388285,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"00363038622"},{"Id":388286,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363039237"},{"Id":388287,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363039314"},{"Id":388288,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00363039707"},{"Id":388289,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 160MG JR","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00363039908"},{"Id":388290,"FormularyType":"OHP","DrugName":"MOTION SICK CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"00363040421"},{"Id":388291,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 100%","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102999","GenericName":"PSYLLIUM POWDER 100%","NDC":"00363040511"},{"Id":388292,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363041105"},{"Id":388293,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363041110"},{"Id":388294,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"00363041327"},{"Id":388295,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363041474"},{"Id":388296,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00363041598"},{"Id":388297,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00363041698"},{"Id":388298,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG STRT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363042062"},{"Id":388299,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG REF","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363042098"},{"Id":388300,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG STRT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363042162"},{"Id":388301,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG REF","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363042198"},{"Id":388302,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363042405"},{"Id":388303,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363042476"},{"Id":388304,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363042816"},{"Id":388305,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363042849"},{"Id":388306,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363042949"},{"Id":388307,"FormularyType":"OHP","DrugName":"HEADACHE REL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00363043052"},{"Id":388308,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363043212"},{"Id":388309,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363043226"},{"Id":388310,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363043837"},{"Id":388311,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363043925"},{"Id":388312,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363043982"},{"Id":388313,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"00363044025"},{"Id":388314,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00363044108"},{"Id":388315,"FormularyType":"OHP","DrugName":"GLYCERN CHLD SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"00363044112"},{"Id":388316,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00363044130"},{"Id":388317,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363044206"},{"Id":388318,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363044278"},{"Id":388319,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00363045174"},{"Id":388320,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00363045574"},{"Id":388321,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363045660"},{"Id":388322,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363045676"},{"Id":388323,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363045678"},{"Id":388324,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00363045774"},{"Id":388325,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00363045802"},{"Id":388326,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00363045865"},{"Id":388327,"FormularyType":"OHP","DrugName":"IBUPROFN 100 CHW JR 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"00363046162"},{"Id":388328,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"00363046510"},{"Id":388329,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00363046526"},{"Id":388330,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00363046604"},{"Id":388331,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363048044"},{"Id":388332,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363048144"},{"Id":388333,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363048316"},{"Id":388334,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363048344"},{"Id":388335,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363048349"},{"Id":388336,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363048462"},{"Id":388337,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363048471"},{"Id":388338,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00363050304"},{"Id":388339,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"00363051111"},{"Id":388340,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"00363051311"},{"Id":388341,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"00363051511"},{"Id":388342,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"00363051518"},{"Id":388343,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363051908"},{"Id":388344,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363051912"},{"Id":388345,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363051915"},{"Id":388346,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363052278"},{"Id":388347,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363052611"},{"Id":388348,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363052621"},{"Id":388349,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363052631"},{"Id":388350,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363052660"},{"Id":388351,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363052690"},{"Id":388352,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"00363052731"},{"Id":388353,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363053206"},{"Id":388354,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363053258"},{"Id":388355,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363053260"},{"Id":388356,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363053278"},{"Id":388357,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00363053964"},{"Id":388358,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363054447"},{"Id":388359,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363054471"},{"Id":388360,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363054478"},{"Id":388361,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363054485"},{"Id":388362,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363056314"},{"Id":388363,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363056317"},{"Id":388364,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363056332"},{"Id":388365,"FormularyType":"OHP","DrugName":"HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00363057131"},{"Id":388366,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00363057501"},{"Id":388367,"FormularyType":"OHP","DrugName":"PAIN/FEVER SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"00363057953"},{"Id":388368,"FormularyType":"OHP","DrugName":"WAL-DRYL ALR TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"00363058572"},{"Id":388369,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363058714"},{"Id":388370,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363058732"},{"Id":388371,"FormularyType":"OHP","DrugName":"CHILD SOOTHE CHW 400MG","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000504","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG","NDC":"00363059608"},{"Id":388372,"FormularyType":"OHP","DrugName":"WAL-DRYL ALR TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"00363059972"},{"Id":388373,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363060075"},{"Id":388374,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363060095"},{"Id":388375,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00363060630"},{"Id":388376,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363060839"},{"Id":388377,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363060847"},{"Id":388378,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363060895"},{"Id":388379,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363060962"},{"Id":388380,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363060998"},{"Id":388381,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363061112"},{"Id":388382,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363061244"},{"Id":388383,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363061246"},{"Id":388384,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363061247"},{"Id":388385,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363061260"},{"Id":388386,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363061265"},{"Id":388387,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363061272"},{"Id":388388,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363061275"},{"Id":388389,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363061344"},{"Id":388390,"FormularyType":"OHP","DrugName":"PINWORM MED SUS 144MG/ML","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"00363061801"},{"Id":388391,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00363062001"},{"Id":388392,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00363062002"},{"Id":388393,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363063112"},{"Id":388394,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00363066026"},{"Id":388395,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363068650"},{"Id":388396,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363069031"},{"Id":388397,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"00363069112"},{"Id":388398,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363069904"},{"Id":388399,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00363070102"},{"Id":388400,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00363071008"},{"Id":388401,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00363071010"},{"Id":388402,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363073402"},{"Id":388403,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363075934"},{"Id":388404,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363076415"},{"Id":388405,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363076430"},{"Id":388406,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"00363078192"},{"Id":388407,"FormularyType":"OHP","DrugName":"WAL-FEX ALRG TAB 60MG 12H","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"00363078324"},{"Id":388408,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078407"},{"Id":388409,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078414"},{"Id":388410,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078415"},{"Id":388411,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078423"},{"Id":388412,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078429"},{"Id":388413,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078430"},{"Id":388414,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078443"},{"Id":388415,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078445"},{"Id":388416,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078475"},{"Id":388417,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00363078490"},{"Id":388418,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00363079164"},{"Id":388419,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00363080626"},{"Id":388420,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"00363080930"},{"Id":388421,"FormularyType":"OHP","DrugName":"ALLERGY NASA SPR 24HR","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"00363081101"},{"Id":388422,"FormularyType":"OHP","DrugName":"ALLERGY NASA SPR 24HR","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"00363081102"},{"Id":388423,"FormularyType":"OHP","DrugName":"WAL-VERT TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"00363082453"},{"Id":388424,"FormularyType":"OHP","DrugName":"WAL-ITIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00363082622"},{"Id":388425,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"00363083143"},{"Id":388426,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"00363083145"},{"Id":388427,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"00363086060"},{"Id":388428,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363087305"},{"Id":388429,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363087308"},{"Id":388430,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363087310"},{"Id":388431,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363087323"},{"Id":388432,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363087367"},{"Id":388433,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363088320"},{"Id":388434,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1% TRT","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"00363088805"},{"Id":388435,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1% TRT","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"00363088816"},{"Id":388436,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00363089488"},{"Id":388437,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00363089588"},{"Id":388438,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00363089653"},{"Id":388439,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00363089688"},{"Id":388440,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00363089726"},{"Id":388441,"FormularyType":"OHP","DrugName":"WAL-FEX ALRG TAB 60MG 12H","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"00363090362"},{"Id":388442,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363091978"},{"Id":388443,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363093604"},{"Id":388444,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00363094940"},{"Id":388445,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363095704"},{"Id":388446,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363095926"},{"Id":388447,"FormularyType":"OHP","DrugName":"ANTACID LIQ SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363112112"},{"Id":388448,"FormularyType":"OHP","DrugName":"ANTACID M SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363112126"},{"Id":388449,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00363121408"},{"Id":388450,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00363121422"},{"Id":388451,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00363121446"},{"Id":388452,"FormularyType":"OHP","DrugName":"NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00363124001"},{"Id":388453,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00363124202"},{"Id":388454,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00363124401"},{"Id":388455,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00363124501"},{"Id":388456,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00363124502"},{"Id":388457,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"00363130101"},{"Id":388458,"FormularyType":"OHP","DrugName":"SOOTHE ULTRA TAB 525MG","DosageForm":"TABS - Tablet","Strength":"525","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000320","GenericName":"BISMUTH SUBSALICYLATE TAB 525 MG","NDC":"00363130202"},{"Id":388459,"FormularyType":"OHP","DrugName":"WAL-ZYR CHLD SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363147526"},{"Id":388460,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363150278"},{"Id":388461,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363161265"},{"Id":388462,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"00363181955"},{"Id":388463,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"00363181974"},{"Id":388464,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00363187101"},{"Id":388465,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00363189802"},{"Id":388466,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00363189803"},{"Id":388467,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00363192112"},{"Id":388468,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00363193112"},{"Id":388469,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00363193126"},{"Id":388470,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00363197364"},{"Id":388471,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"00363208001"},{"Id":388472,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"00363208002"},{"Id":388473,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363208812"},{"Id":388474,"FormularyType":"OHP","DrugName":"WAL-ITIN CHL SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00363209208"},{"Id":388475,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"00363210017"},{"Id":388476,"FormularyType":"OHP","DrugName":"ANTACID MAX CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"00363210316"},{"Id":388477,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00363210808"},{"Id":388478,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00363210901"},{"Id":388479,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"00363214002"},{"Id":388480,"FormularyType":"OHP","DrugName":"ANTACID M SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00363307312"},{"Id":388481,"FormularyType":"OHP","DrugName":"ATHLETE FOOT POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"00363311525"},{"Id":388482,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00363330152"},{"Id":388483,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00363331126"},{"Id":388484,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"00363410040"},{"Id":388485,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG REF","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363412250"},{"Id":388486,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG STRT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363412262"},{"Id":388487,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG REF","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363412298"},{"Id":388488,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG REF","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363414950"},{"Id":388489,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG STRT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363414962"},{"Id":388490,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG REF","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363414998"},{"Id":388491,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363419005"},{"Id":388492,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363419010"},{"Id":388493,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00363440019"},{"Id":388494,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00363450108"},{"Id":388495,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"00363500024"},{"Id":388496,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363645014"},{"Id":388497,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363645250"},{"Id":388498,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363645510"},{"Id":388499,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00363645550"},{"Id":388500,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363689815"},{"Id":388501,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363689825"},{"Id":388502,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00363695808"},{"Id":388503,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00363700874"},{"Id":388504,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00363706510"},{"Id":388505,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00363710004"},{"Id":388506,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH/RED","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"00363713005"},{"Id":388507,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH REL","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"00363713125"},{"Id":388508,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00363716238"},{"Id":388509,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363726960"},{"Id":388510,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00363726978"},{"Id":388511,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00363800101"},{"Id":388512,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH REL","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"00363802239"},{"Id":388513,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00363816638"},{"Id":388514,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00363873501"},{"Id":388515,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00363876060"},{"Id":388516,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"00363899310"},{"Id":388517,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"00363906000"},{"Id":388518,"FormularyType":"OHP","DrugName":"SOOTHE TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"00363912540"},{"Id":388519,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00363915020"},{"Id":388520,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00363920190"},{"Id":388521,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00363933010"},{"Id":388522,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00363944008"},{"Id":388523,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00363957072"},{"Id":388524,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00363961150"},{"Id":388525,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00363962072"},{"Id":388526,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363999210"},{"Id":388527,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363999315"},{"Id":388528,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00363999321"},{"Id":388529,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"00378001401"},{"Id":388530,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"00378001801"},{"Id":388531,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"00378001805"},{"Id":388532,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"00378003201"},{"Id":388533,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"00378003210"},{"Id":388534,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"00378004701"},{"Id":388535,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"00378004710"},{"Id":388536,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"00378005301"},{"Id":388537,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"00378008501"},{"Id":388538,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"00378008801"},{"Id":388539,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"00378009401"},{"Id":388540,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00378013701"},{"Id":388541,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00378013710"},{"Id":388542,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100310","GenericName":"TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00378014491"},{"Id":388543,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00378018101"},{"Id":388544,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00378018105"},{"Id":388545,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"00378018201"},{"Id":388546,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"00378018210"},{"Id":388547,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"00378018301"},{"Id":388548,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"00378018310"},{"Id":388549,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"00378018401"},{"Id":388550,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"00378018410"},{"Id":388551,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"00378018501"},{"Id":388552,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"00378018505"},{"Id":388553,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"00378018701"},{"Id":388554,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"00378021301"},{"Id":388555,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"00378021310"},{"Id":388556,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"00378021801"},{"Id":388557,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"00378021810"},{"Id":388558,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"00378022201"},{"Id":388559,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"00378022210"},{"Id":388560,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"00378023101"},{"Id":388561,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"00378023110"},{"Id":388562,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"00378024301"},{"Id":388563,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"00378024305"},{"Id":388564,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"00378026591"},{"Id":388565,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"00378026691"},{"Id":388566,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"00378027493"},{"Id":388567,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000310","GenericName":"CIMETIDINE TAB 300 MG","NDC":"00378031701"},{"Id":388568,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000315","GenericName":"CIMETIDINE TAB 400 MG","NDC":"00378037201"},{"Id":388569,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"00378040301"},{"Id":388570,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"00378040305"},{"Id":388571,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200310","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","NDC":"00378042401"},{"Id":388572,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200320","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"00378043401"},{"Id":388573,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"00378043701"},{"Id":388574,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 100-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200325","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG","NDC":"00378044501"},{"Id":388575,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"00378050101"},{"Id":388576,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"00378050301"},{"Id":388577,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"00378050501"},{"Id":388578,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000320","GenericName":"CIMETIDINE TAB 800 MG","NDC":"00378054101"},{"Id":388579,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00378064001"},{"Id":388580,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00378064010"},{"Id":388581,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00378064101"},{"Id":388582,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00378064110"},{"Id":388583,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00378064201"},{"Id":388584,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00378064205"},{"Id":388585,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00378064210"},{"Id":388586,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"00378075701"},{"Id":388587,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"00378075710"},{"Id":388588,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"00378110101"},{"Id":388589,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"00378110110"},{"Id":388590,"FormularyType":"OHP","DrugName":"SORAFENIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533060400320","GenericName":"SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"00378120178"},{"Id":388591,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"00378137578"},{"Id":388592,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00378180010"},{"Id":388593,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00378180077"},{"Id":388594,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00378180310"},{"Id":388595,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00378180377"},{"Id":388596,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00378180510"},{"Id":388597,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00378180577"},{"Id":388598,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00378180710"},{"Id":388599,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00378180777"},{"Id":388600,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00378180910"},{"Id":388601,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00378180977"},{"Id":388602,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00378181110"},{"Id":388603,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00378181177"},{"Id":388604,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00378181310"},{"Id":388605,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00378181377"},{"Id":388606,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00378181510"},{"Id":388607,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00378181577"},{"Id":388608,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00378181710"},{"Id":388609,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00378181777"},{"Id":388610,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00378181910"},{"Id":388611,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00378181977"},{"Id":388612,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"00378182177"},{"Id":388613,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"00378182310"},{"Id":388614,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"00378182377"},{"Id":388615,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"00378190101"},{"Id":388616,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"00378190201"},{"Id":388617,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"00378190301"},{"Id":388618,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"00378193093"},{"Id":388619,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"00378193501"},{"Id":388620,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"00378193528"},{"Id":388621,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"00378193601"},{"Id":388622,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"00378193628"},{"Id":388623,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"00378193701"},{"Id":388624,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"00378193728"},{"Id":388625,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"00378194001"},{"Id":388626,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"00378194021"},{"Id":388627,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"00378194101"},{"Id":388628,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"00378194121"},{"Id":388629,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"00378194201"},{"Id":388630,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"00378194221"},{"Id":388631,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"00378204501"},{"Id":388632,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"00378204601"},{"Id":388633,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"00378204701"},{"Id":388634,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"00378210001"},{"Id":388635,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"00378210005"},{"Id":388636,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"00378214601"},{"Id":388637,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"00378214605"},{"Id":388638,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"00378224577"},{"Id":388639,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"00378224693"},{"Id":388640,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00378225005"},{"Id":388641,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"00378230201"},{"Id":388642,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"00378230210"},{"Id":388643,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00378235077"},{"Id":388644,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"00378235093"},{"Id":388645,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"00378235177"},{"Id":388646,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"00378235193"},{"Id":388647,"FormularyType":"OHP","DrugName":"PHENYTEK CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200120","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 200 MG","NDC":"00378267001"},{"Id":388648,"FormularyType":"OHP","DrugName":"PHENYTEK CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200120","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 200 MG","NDC":"00378267093"},{"Id":388649,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"00378292077"},{"Id":388650,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"00378292093"},{"Id":388651,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"00378292177"},{"Id":388652,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"00378292193"},{"Id":388653,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"00378292277"},{"Id":388654,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"00378292293"},{"Id":388655,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 16-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200320","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG","NDC":"00378300177"},{"Id":388656,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200340","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG","NDC":"00378300277"},{"Id":388657,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200350","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-25 MG","NDC":"00378300377"},{"Id":388658,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"00378306577"},{"Id":388659,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"00378306605"},{"Id":388660,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"00378306677"},{"Id":388661,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"00378320501"},{"Id":388662,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"00378320525"},{"Id":388663,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100310","GenericName":"CANDESARTAN CILEXETIL TAB 4 MG","NDC":"00378322477"},{"Id":388664,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100310","GenericName":"CANDESARTAN CILEXETIL TAB 4 MG","NDC":"00378322493"},{"Id":388665,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"00378322577"},{"Id":388666,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"00378322593"},{"Id":388667,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"00378323177"},{"Id":388668,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"00378323193"},{"Id":388669,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"00378323277"},{"Id":388670,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"00378323293"},{"Id":388671,"FormularyType":"OHP","DrugName":"ETOPOSIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"MITOTIC INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21500010000120","GenericName":"ETOPOSIDE CAP 50 MG","NDC":"00378326632"},{"Id":388672,"FormularyType":"OHP","DrugName":"ETOPOSIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"MITOTIC INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21500010000120","GenericName":"ETOPOSIDE CAP 50 MG","NDC":"00378326694"},{"Id":388673,"FormularyType":"OHP","DrugName":"XULANE DIS 150-35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"00378334016"},{"Id":388674,"FormularyType":"OHP","DrugName":"XULANE DIS 150-35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"00378334053"},{"Id":388675,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008810","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR","NDC":"00378334916"},{"Id":388676,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008810","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR","NDC":"00378334999"},{"Id":388677,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008820","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR","NDC":"00378335016"},{"Id":388678,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008820","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR","NDC":"00378335099"},{"Id":388679,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008830","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR","NDC":"00378335116"},{"Id":388680,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008830","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR","NDC":"00378335199"},{"Id":388681,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008840","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR","NDC":"00378335216"},{"Id":388682,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008840","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR","NDC":"00378335299"},{"Id":388683,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTWK - Patch Weekly","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008815","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR)","NDC":"00378336016"},{"Id":388684,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTWK - Patch Weekly","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008815","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR)","NDC":"00378336099"},{"Id":388685,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.06MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.06","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008824","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR","NDC":"00378336116"},{"Id":388686,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.06MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.06","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008824","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR","NDC":"00378336199"},{"Id":388687,"FormularyType":"OHP","DrugName":"FOSAMPRENAVI TAB 700MG","DosageForm":"TABS - Tablet","Strength":"700","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104525100330","GenericName":"FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV)","NDC":"00378352091"},{"Id":388688,"FormularyType":"OHP","DrugName":"MERCAPTOPUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300040000305","GenericName":"MERCAPTOPURINE TAB 50 MG","NDC":"00378354752"},{"Id":388689,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100310","GenericName":"CETIRIZINE HCL TAB 5 MG","NDC":"00378363501"},{"Id":388690,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00378363701"},{"Id":388691,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00378363705"},{"Id":388692,"FormularyType":"OHP","DrugName":"PHENYTEK CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200130","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 300 MG","NDC":"00378375001"},{"Id":388693,"FormularyType":"OHP","DrugName":"PHENYTEK CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200130","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 300 MG","NDC":"00378375093"},{"Id":388694,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"00378395005"},{"Id":388695,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"00378395077"},{"Id":388696,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"00378395105"},{"Id":388697,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"00378395177"},{"Id":388698,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"00378395205"},{"Id":388699,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"00378395277"},{"Id":388700,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"00378395305"},{"Id":388701,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"00378395377"},{"Id":388702,"FormularyType":"OHP","DrugName":"NEVIRAPINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050000320","GenericName":"NEVIRAPINE TAB 200 MG","NDC":"00378405091"},{"Id":388703,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"00378410591"},{"Id":388704,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"00378427093"},{"Id":388705,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"00378427193"},{"Id":388706,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"00378427577"},{"Id":388707,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"00378427593"},{"Id":388708,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"00378427677"},{"Id":388709,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"00378427693"},{"Id":388710,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"00378428785"},{"Id":388711,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"00378428808"},{"Id":388712,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"00378428885"},{"Id":388713,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"00378447205"},{"Id":388714,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"00378456005"},{"Id":388715,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"00378456077"},{"Id":388716,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00378456105"},{"Id":388717,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00378456177"},{"Id":388718,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 37.5MG","DosageForm":"TABS - Tablet","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100307","GenericName":"METOPROLOL TARTRATE TAB 37.5 MG","NDC":"00378459301"},{"Id":388719,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100312","GenericName":"METOPROLOL TARTRATE TAB 75 MG","NDC":"00378459401"},{"Id":388720,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"00378459510"},{"Id":388721,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"00378459577"},{"Id":388722,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"00378459610"},{"Id":388723,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"00378459677"},{"Id":388724,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"00378459710"},{"Id":388725,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"00378461916"},{"Id":388726,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"00378461926"},{"Id":388727,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"00378462016"},{"Id":388728,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"00378462026"},{"Id":388729,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"00378462116"},{"Id":388730,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"00378462126"},{"Id":388731,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"00378462216"},{"Id":388732,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"00378462226"},{"Id":388733,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"00378462316"},{"Id":388734,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"00378462326"},{"Id":388735,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"00378464016"},{"Id":388736,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"00378464026"},{"Id":388737,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"00378464116"},{"Id":388738,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"00378464126"},{"Id":388739,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"00378464216"},{"Id":388740,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"00378464226"},{"Id":388741,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"00378464316"},{"Id":388742,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"00378464326"},{"Id":388743,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"00378464416"},{"Id":388744,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"00378464426"},{"Id":388745,"FormularyType":"OHP","DrugName":"FLUOROURACIL CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030003730","GenericName":"FLUOROURACIL CREAM 5%","NDC":"00378479106"},{"Id":388746,"FormularyType":"OHP","DrugName":"NEVIRAPINE TAB 400MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050007520","GenericName":"NEVIRAPINE TAB ER 24HR 400 MG","NDC":"00378489093"},{"Id":388747,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"00378508973"},{"Id":388748,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"00378509073"},{"Id":388749,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"00378509185"},{"Id":388750,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100320","GenericName":"PRASUGREL HCL TAB 5 MG (BASE EQUIV)","NDC":"00378518593"},{"Id":388751,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100330","GenericName":"PRASUGREL HCL TAB 10 MG (BASE EQUIV)","NDC":"00378518693"},{"Id":388752,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"00378527001"},{"Id":388753,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"00378527101"},{"Id":388754,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"00378527201"},{"Id":388755,"FormularyType":"OHP","DrugName":"EMTRIC/RILPI TAB TENOF DF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903400320","GenericName":"EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB 200-25-300 MG","NDC":"00378544093"},{"Id":388756,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"00378561505"},{"Id":388757,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"00378561578"},{"Id":388758,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"00378561705"},{"Id":388759,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"00378561778"},{"Id":388760,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"00378561991"},{"Id":388761,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"00378563059"},{"Id":388762,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"00378563159"},{"Id":388763,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"00378563259"},{"Id":388764,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"00378580793"},{"Id":388765,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"00378581377"},{"Id":388766,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"00378581477"},{"Id":388767,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"00378581577"},{"Id":388768,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"00378606001"},{"Id":388769,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"00378609001"},{"Id":388770,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"00378612001"},{"Id":388771,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"00378617201"},{"Id":388772,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"00378617301"},{"Id":388773,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"00378617401"},{"Id":388774,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107020","GenericName":"VERAPAMIL HCL CAP ER 24HR 120 MG","NDC":"00378632001"},{"Id":388775,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"00378632177"},{"Id":388776,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"00378632277"},{"Id":388777,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"00378632377"},{"Id":388778,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"00378632477"},{"Id":388779,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"00378632577"},{"Id":388780,"FormularyType":"OHP","DrugName":"ACAMPRO CAL TAB 333MG","DosageForm":"TBEC - Tablet DR","Strength":"333","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802010200620","GenericName":"ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","NDC":"00378633380"},{"Id":388781,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107025","GenericName":"VERAPAMIL HCL CAP ER 24HR 180 MG","NDC":"00378638001"},{"Id":388782,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107035","GenericName":"VERAPAMIL HCL CAP ER 24HR 240 MG","NDC":"00378644001"},{"Id":388783,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00378655053"},{"Id":388784,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00378661185"},{"Id":388785,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00378661193"},{"Id":388786,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00378661285"},{"Id":388787,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00378661293"},{"Id":388788,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00378661385"},{"Id":388789,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00378661393"},{"Id":388790,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00378661485"},{"Id":388791,"FormularyType":"OHP","DrugName":"AMNESTEEM CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00378661493"},{"Id":388792,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"00378667828"},{"Id":388793,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"00378667928"},{"Id":388794,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"00378668028"},{"Id":388795,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"00378668128"},{"Id":388796,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"00378668877"},{"Id":388797,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"00378668910"},{"Id":388798,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"00378668977"},{"Id":388799,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"00378685477"},{"Id":388800,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"00378685577"},{"Id":388801,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"00378685677"},{"Id":388802,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"00378685777"},{"Id":388803,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"00378685877"},{"Id":388804,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"00378685977"},{"Id":388805,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"00378686077"},{"Id":388806,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"00378692078"},{"Id":388807,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"00378692191"},{"Id":388808,"FormularyType":"OHP","DrugName":"GLATIRAMER INJ 20MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240003010E520","GenericName":"GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML","NDC":"00378696032"},{"Id":388809,"FormularyType":"OHP","DrugName":"GLATIRAMER INJ 20MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240003010E520","GenericName":"GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML","NDC":"00378696093"},{"Id":388810,"FormularyType":"OHP","DrugName":"GLATIRAMER INJ 40MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240003010E540","GenericName":"GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML","NDC":"00378696112"},{"Id":388811,"FormularyType":"OHP","DrugName":"GLATIRAMER INJ 40MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240003010E540","GenericName":"GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML","NDC":"00378696132"},{"Id":388812,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"00378698501"},{"Id":388813,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"00378698601"},{"Id":388814,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"00378698789"},{"Id":388815,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 3%","DosageForm":"NEBU - Nebulization solution","Strength":"3","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002530","GenericName":"SODIUM CHLORIDE SOLN NEBU 3%","NDC":"00378699789"},{"Id":388816,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000110","GenericName":"ACITRETIN CAP 10 MG","NDC":"00378702093"},{"Id":388817,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000125","GenericName":"ACITRETIN CAP 25 MG","NDC":"00378702393"},{"Id":388818,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"00378705752"},{"Id":388819,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"00378705798"},{"Id":388820,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"00378705852"},{"Id":388821,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"00378705898"},{"Id":388822,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100105","GenericName":"BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT)","NDC":"00378709601"},{"Id":388823,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100105","GenericName":"BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT)","NDC":"00378709693"},{"Id":388824,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"00378718505"},{"Id":388825,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"00378718605"},{"Id":388826,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"00378718705"},{"Id":388827,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"00378727253"},{"Id":388828,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"00378727285"},{"Id":388829,"FormularyType":"OHP","DrugName":"NORETH/ETHIN TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"00378727453"},{"Id":388830,"FormularyType":"OHP","DrugName":"NORETH/ETHIN TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"00378727485"},{"Id":388831,"FormularyType":"OHP","DrugName":"NORETH/ETHIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"00378728053"},{"Id":388832,"FormularyType":"OHP","DrugName":"NORETH/ETHIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"00378728085"},{"Id":388833,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"00378728485"},{"Id":388834,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"00378728490"},{"Id":388835,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"00378728753"},{"Id":388836,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"00378728785"},{"Id":388837,"FormularyType":"OHP","DrugName":"NOR/EST/FF TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"00378728853"},{"Id":388838,"FormularyType":"OHP","DrugName":"NOR/EST/FF TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"00378728885"},{"Id":388839,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"00378729253"},{"Id":388840,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"00378729285"},{"Id":388841,"FormularyType":"OHP","DrugName":"DESO/ETHINYL TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"00378729653"},{"Id":388842,"FormularyType":"OHP","DrugName":"NORE/ETH/FER CHW 0.4MG-35","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600520","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","NDC":"00378729753"},{"Id":388843,"FormularyType":"OHP","DrugName":"NORE/ETH/FER CHW 0.4MG-35","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600520","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","NDC":"00378729785"},{"Id":388844,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"00378730053"},{"Id":388845,"FormularyType":"OHP","DrugName":"ETHYNODIOL TAB 1-50","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200320","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG","NDC":"00378730653"},{"Id":388846,"FormularyType":"OHP","DrugName":"ETHYNODIOL TAB 1-50","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200320","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG","NDC":"00378730685"},{"Id":388847,"FormularyType":"OHP","DrugName":"ETHY ETH EST TAB 1-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00378730753"},{"Id":388848,"FormularyType":"OHP","DrugName":"ETHY ETH EST TAB 1-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00378730785"},{"Id":388849,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300350","GenericName":"LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG","NDC":"00378731685"},{"Id":388850,"FormularyType":"OHP","DrugName":"BREYNA AER 80/4.5","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902413220","GenericName":"BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT","NDC":"00378750232"},{"Id":388851,"FormularyType":"OHP","DrugName":"BREYNA AER 160/4.5","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902413240","GenericName":"BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 160-4.5 MCG/ACT","NDC":"00378750332"},{"Id":388852,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00378797031"},{"Id":388853,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00378797052"},{"Id":388854,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00378797055"},{"Id":388855,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00378797091"},{"Id":388856,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00378797093"},{"Id":388857,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"00378801593"},{"Id":388858,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"00378803005"},{"Id":388859,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"00378803077"},{"Id":388860,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"00378803093"},{"Id":388861,"FormularyType":"OHP","DrugName":"GLUCAGON INJ 1MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010002105","GenericName":"GLUCAGON FOR INJ 1 MG","NDC":"00378806790"},{"Id":388862,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"00378808220"},{"Id":388863,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"00378808245"},{"Id":388864,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00378827031"},{"Id":388865,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00378827052"},{"Id":388866,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00378827055"},{"Id":388867,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00378827091"},{"Id":388868,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00378827093"},{"Id":388869,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"00378876516"},{"Id":388870,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"00378876593"},{"Id":388871,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"00378876616"},{"Id":388872,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"00378876693"},{"Id":388873,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"00378876716"},{"Id":388874,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"00378876793"},{"Id":388875,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"00378876816"},{"Id":388876,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"00378876893"},{"Id":388877,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"00378877035"},{"Id":388878,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.1MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008510","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR","NDC":"00378910216"},{"Id":388879,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.1MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008510","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR","NDC":"00378910293"},{"Id":388880,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.2MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008520","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR","NDC":"00378910416"},{"Id":388881,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.2MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008520","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR","NDC":"00378910493"},{"Id":388882,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.4MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008540","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR","NDC":"00378911216"},{"Id":388883,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.4MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008540","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR","NDC":"00378911293"},{"Id":388884,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.6MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008550","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR","NDC":"00378911616"},{"Id":388885,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.6MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008550","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR","NDC":"00378911693"},{"Id":388886,"FormularyType":"OHP","DrugName":"FENTANYL DIS 12MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008610","GenericName":"FENTANYL TD PATCH 72HR 12 MCG/HR","NDC":"00378911916"},{"Id":388887,"FormularyType":"OHP","DrugName":"FENTANYL DIS 12MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008610","GenericName":"FENTANYL TD PATCH 72HR 12 MCG/HR","NDC":"00378911998"},{"Id":388888,"FormularyType":"OHP","DrugName":"FENTANYL DIS 25MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008620","GenericName":"FENTANYL TD PATCH 72HR 25 MCG/HR","NDC":"00378912116"},{"Id":388889,"FormularyType":"OHP","DrugName":"FENTANYL DIS 25MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008620","GenericName":"FENTANYL TD PATCH 72HR 25 MCG/HR","NDC":"00378912198"},{"Id":388890,"FormularyType":"OHP","DrugName":"FENTANYL DIS 50MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008630","GenericName":"FENTANYL TD PATCH 72HR 50 MCG/HR","NDC":"00378912216"},{"Id":388891,"FormularyType":"OHP","DrugName":"FENTANYL DIS 50MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008630","GenericName":"FENTANYL TD PATCH 72HR 50 MCG/HR","NDC":"00378912298"},{"Id":388892,"FormularyType":"OHP","DrugName":"FENTANYL DIS 75MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008640","GenericName":"FENTANYL TD PATCH 72HR 75 MCG/HR","NDC":"00378912316"},{"Id":388893,"FormularyType":"OHP","DrugName":"FENTANYL DIS 75MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008640","GenericName":"FENTANYL TD PATCH 72HR 75 MCG/HR","NDC":"00378912398"},{"Id":388894,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"00378912416"},{"Id":388895,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"00378912498"},{"Id":388896,"FormularyType":"OHP","DrugName":"FENTANYL DIS 37.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008626","GenericName":"FENTANYL TD PATCH 72HR 37.5 MCG/HR","NDC":"00378912516"},{"Id":388897,"FormularyType":"OHP","DrugName":"FENTANYL DIS 37.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008626","GenericName":"FENTANYL TD PATCH 72HR 37.5 MCG/HR","NDC":"00378912598"},{"Id":388898,"FormularyType":"OHP","DrugName":"FENTANYL DIS 62.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"62.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008635","GenericName":"FENTANYL TD PATCH 72HR 62.5 MCG/HR","NDC":"00378912616"},{"Id":388899,"FormularyType":"OHP","DrugName":"FENTANYL DIS 62.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"62.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008635","GenericName":"FENTANYL TD PATCH 72HR 62.5 MCG/HR","NDC":"00378912698"},{"Id":388900,"FormularyType":"OHP","DrugName":"FENTANYL DIS 87.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"87.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008645","GenericName":"FENTANYL TD PATCH 72HR 87.5 MCG/HR","NDC":"00378912716"},{"Id":388901,"FormularyType":"OHP","DrugName":"FENTANYL DIS 87.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"87.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008645","GenericName":"FENTANYL TD PATCH 72HR 87.5 MCG/HR","NDC":"00378912798"},{"Id":388902,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00378920535"},{"Id":388903,"FormularyType":"OHP","DrugName":"WIXELA INHUB AER 100/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708020","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/ACT","NDC":"00378932032"},{"Id":388904,"FormularyType":"OHP","DrugName":"WIXELA INHUB AER 250/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708030","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/ACT","NDC":"00378932132"},{"Id":388905,"FormularyType":"OHP","DrugName":"WIXELA INHUB AER 500/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708040","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/ACT","NDC":"00378932232"},{"Id":388906,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"00378965132"},{"Id":388907,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"00378965150"},{"Id":388908,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00378967130"},{"Id":388909,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00378967131"},{"Id":388910,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00378967160"},{"Id":388911,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00378967193"},{"Id":388912,"FormularyType":"OHP","DrugName":"HYDROCORT LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"00394085932"},{"Id":388913,"FormularyType":"OHP","DrugName":"FLAVOR BLEND SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"00395008916"},{"Id":388914,"FormularyType":"OHP","DrugName":"FLAVOR BLEND SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"00395008928"},{"Id":388915,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395009016"},{"Id":388916,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395009028"},{"Id":388917,"FormularyType":"OHP","DrugName":"FLAVOR PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"00395009116"},{"Id":388918,"FormularyType":"OHP","DrugName":"FLAVOR PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"00395009128"},{"Id":388919,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SYP S/F","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395009416"},{"Id":388920,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SYP S/F","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395009428"},{"Id":388921,"FormularyType":"OHP","DrugName":"VERSAFREE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395012516"},{"Id":388922,"FormularyType":"OHP","DrugName":"VERSAFREE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395012528"},{"Id":388923,"FormularyType":"OHP","DrugName":"VERSAPLUS SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395012616"},{"Id":388924,"FormularyType":"OHP","DrugName":"VERSAPLUS SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395012628"},{"Id":388925,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"85","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"00395266116"},{"Id":388926,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"85","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"00395266128"},{"Id":388927,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"85","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"00395266175"},{"Id":388928,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"82.3","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"00395266216"},{"Id":388929,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"82.3","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"00395266228"},{"Id":388930,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"82.3","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"00395916701"},{"Id":388931,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"82.3","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"00395916702"},{"Id":388932,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SOL SF DYE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395916801"},{"Id":388933,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SOL SF DYE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395916802"},{"Id":388934,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SOL DYE FREE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395916901"},{"Id":388935,"FormularyType":"OHP","DrugName":"FLAVOR SWEET SOL DYE FREE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00395916902"},{"Id":388936,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 60","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005440","GenericName":"DIAPHRAGM WIDE SEAL 60 MM","NDC":"00396401060"},{"Id":388937,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 65","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005445","GenericName":"DIAPHRAGM WIDE SEAL 65 MM","NDC":"00396401065"},{"Id":388938,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 70","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005450","GenericName":"DIAPHRAGM WIDE SEAL 70 MM","NDC":"00396401070"},{"Id":388939,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 75","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005455","GenericName":"DIAPHRAGM WIDE SEAL 75 MM","NDC":"00396401075"},{"Id":388940,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 80","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005460","GenericName":"DIAPHRAGM WIDE SEAL 80 MM","NDC":"00396401080"},{"Id":388941,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 85","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005465","GenericName":"DIAPHRAGM WIDE SEAL 85 MM","NDC":"00396401085"},{"Id":388942,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 90","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005470","GenericName":"DIAPHRAGM WIDE SEAL 90 MM","NDC":"00396401090"},{"Id":388943,"FormularyType":"OHP","DrugName":"WIDE-SEAL DPR KIT 95","DosageForm":"DPRH - Diaphragm","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402080005475","GenericName":"DIAPHRAGM WIDE SEAL 95 MM","NDC":"00396401095"},{"Id":388944,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012301"},{"Id":388945,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012305"},{"Id":388946,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012310"},{"Id":388947,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012312"},{"Id":388948,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012323"},{"Id":388949,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012330"},{"Id":388950,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"00406012362"},{"Id":388951,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406012401"},{"Id":388952,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406012405"},{"Id":388953,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406012410"},{"Id":388954,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406012412"},{"Id":388955,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406012423"},{"Id":388956,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406012462"},{"Id":388957,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012501"},{"Id":388958,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012505"},{"Id":388959,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012510"},{"Id":388960,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012512"},{"Id":388961,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012523"},{"Id":388962,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012560"},{"Id":388963,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"00406012562"},{"Id":388964,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 27MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100465","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","NDC":"00406012701"},{"Id":388965,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"00406013601"},{"Id":388966,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 54MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100480","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","NDC":"00406015401"},{"Id":388967,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050310","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","NDC":"00406048301"},{"Id":388968,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"00406048401"},{"Id":388969,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"00406048403"},{"Id":388970,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"00406048410"},{"Id":388971,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"00406048423"},{"Id":388972,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"00406048462"},{"Id":388973,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"00406048501"},{"Id":388974,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"00406048505"},{"Id":388975,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"00406051201"},{"Id":388976,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"00406051205"},{"Id":388977,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"00406051223"},{"Id":388978,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"00406051262"},{"Id":388979,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406052201"},{"Id":388980,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406052205"},{"Id":388981,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406052223"},{"Id":388982,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00406052262"},{"Id":388983,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"00406052301"},{"Id":388984,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"00406052305"},{"Id":388985,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"00406052323"},{"Id":388986,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"00406052362"},{"Id":388987,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"00406055201"},{"Id":388988,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"00406055223"},{"Id":388989,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"00406055262"},{"Id":388990,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"00406114201"},{"Id":388991,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"00406114401"},{"Id":388992,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"00406114601"},{"Id":388993,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"00406117001"},{"Id":388994,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"00406117003"},{"Id":388995,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"00406123601"},{"Id":388996,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"00406123610"},{"Id":388997,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100403","GenericName":"METHYLPHENIDATE HCL TAB ER 10 MG","NDC":"00406144501"},{"Id":388998,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100405","GenericName":"METHYLPHENIDATE HCL TAB ER 20 MG","NDC":"00406147301"},{"Id":388999,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 10MG CD","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100210","GenericName":"METHYLPHENIDATE HCL CAP ER 10 MG (CD)","NDC":"00406181001"},{"Id":389000,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 20MG CD","DosageForm":"CPCR - Capsule ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100220","GenericName":"METHYLPHENIDATE HCL CAP ER 20 MG (CD)","NDC":"00406182001"},{"Id":389001,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 30MG CD","DosageForm":"CPCR - Capsule ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100230","GenericName":"METHYLPHENIDATE HCL CAP ER 30 MG (CD)","NDC":"00406183001"},{"Id":389002,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 40MG CD","DosageForm":"CPCR - Capsule ER","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100240","GenericName":"METHYLPHENIDATE HCL CAP ER 40 MG (CD)","NDC":"00406184001"},{"Id":389003,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 50MG CD","DosageForm":"CPCR - Capsule ER","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100250","GenericName":"METHYLPHENIDATE HCL CAP ER 50 MG (CD)","NDC":"00406185001"},{"Id":389004,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 60MG CD","DosageForm":"CPCR - Capsule ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100260","GenericName":"METHYLPHENIDATE HCL CAP ER 60 MG (CD)","NDC":"00406186001"},{"Id":389005,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"00406205310"},{"Id":389006,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"00406205401"},{"Id":389007,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"00406205410"},{"Id":389008,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"00406511101"},{"Id":389009,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"00406511201"},{"Id":389010,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"00406511301"},{"Id":389011,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"00406511401"},{"Id":389012,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"00406511501"},{"Id":389013,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"00406511601"},{"Id":389014,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"00406511701"},{"Id":389015,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100310","GenericName":"MORPHINE SULFATE TAB 15 MG","NDC":"00406511801"},{"Id":389016,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100310","GenericName":"MORPHINE SULFATE TAB 15 MG","NDC":"00406511823"},{"Id":389017,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100310","GenericName":"MORPHINE SULFATE TAB 15 MG","NDC":"00406511862"},{"Id":389018,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100315","GenericName":"MORPHINE SULFATE TAB 30 MG","NDC":"00406511901"},{"Id":389019,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100315","GenericName":"MORPHINE SULFATE TAB 30 MG","NDC":"00406511923"},{"Id":389020,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100315","GenericName":"MORPHINE SULFATE TAB 30 MG","NDC":"00406511962"},{"Id":389021,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"00406701203"},{"Id":389022,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"00406701803"},{"Id":389023,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"00406771160"},{"Id":389024,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00406800312"},{"Id":389025,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00406800315"},{"Id":389026,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00406800324"},{"Id":389027,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"00406800330"},{"Id":389028,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"00406800503"},{"Id":389029,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"00406802003"},{"Id":389030,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"00406831501"},{"Id":389031,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"00406831523"},{"Id":389032,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"00406831562"},{"Id":389033,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 200MG ER","DosageForm":"TBCR - Tablet ER","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100480","GenericName":"MORPHINE SULFATE TAB ER 200 MG","NDC":"00406832001"},{"Id":389034,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"00406833001"},{"Id":389035,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"00406833023"},{"Id":389036,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"00406833062"},{"Id":389037,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"00406838001"},{"Id":389038,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"00406838023"},{"Id":389039,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"00406838062"},{"Id":389040,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"00406839001"},{"Id":389041,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"00406839023"},{"Id":389042,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"00406839062"},{"Id":389043,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"00406851001"},{"Id":389044,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"00406851062"},{"Id":389045,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"00406851501"},{"Id":389046,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"00406851523"},{"Id":389047,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"00406851562"},{"Id":389048,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"00406852001"},{"Id":389049,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"00406853001"},{"Id":389050,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"00406853023"},{"Id":389051,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"00406853062"},{"Id":389052,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00406855605"},{"Id":389053,"FormularyType":"OHP","DrugName":"OXYCODONE CON 100/5ML","DosageForm":"CONC - Concentrate","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075101320","GenericName":"OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML)","NDC":"00406855730"},{"Id":389054,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"00406888401"},{"Id":389055,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"00406888501"},{"Id":389056,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"00406889101"},{"Id":389057,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"00406889201"},{"Id":389058,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"00406889301"},{"Id":389059,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"00406889401"},{"Id":389060,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"00406895101"},{"Id":389061,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"00406895201"},{"Id":389062,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"00406895301"},{"Id":389063,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"00406895401"},{"Id":389064,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"00406895501"},{"Id":389065,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"00406895601"},{"Id":389066,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"00406895801"},{"Id":389067,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"00406895901"},{"Id":389068,"FormularyType":"OHP","DrugName":"DEXTROAMPHET CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020107005","GenericName":"DEXTROAMPHETAMINE SULFATE CAP ER 24HR 5 MG","NDC":"00406896001"},{"Id":389069,"FormularyType":"OHP","DrugName":"DEXTROAMPHET CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020107010","GenericName":"DEXTROAMPHETAMINE SULFATE CAP ER 24HR 10 MG","NDC":"00406896101"},{"Id":389070,"FormularyType":"OHP","DrugName":"DEXTROAMPHET CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020107015","GenericName":"DEXTROAMPHETAMINE SULFATE CAP ER 24HR 15 MG","NDC":"00406896201"},{"Id":389071,"FormularyType":"OHP","DrugName":"FENTANYL DIS 37.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008626","GenericName":"FENTANYL TD PATCH 72HR 37.5 MCG/HR","NDC":"00406903776"},{"Id":389072,"FormularyType":"OHP","DrugName":"FENTANYL DIS 62.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"62.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008635","GenericName":"FENTANYL TD PATCH 72HR 62.5 MCG/HR","NDC":"00406906276"},{"Id":389073,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"00406910076"},{"Id":389074,"FormularyType":"OHP","DrugName":"FENTANYL DIS 12MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008610","GenericName":"FENTANYL TD PATCH 72HR 12 MCG/HR","NDC":"00406911276"},{"Id":389075,"FormularyType":"OHP","DrugName":"FENTANYL DIS 25MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008620","GenericName":"FENTANYL TD PATCH 72HR 25 MCG/HR","NDC":"00406912576"},{"Id":389076,"FormularyType":"OHP","DrugName":"FENTANYL DIS 50MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008630","GenericName":"FENTANYL TD PATCH 72HR 50 MCG/HR","NDC":"00406915076"},{"Id":389077,"FormularyType":"OHP","DrugName":"FENTANYL DIS 75MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008640","GenericName":"FENTANYL TD PATCH 72HR 75 MCG/HR","NDC":"00406917576"},{"Id":389078,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409002401"},{"Id":389079,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409002410"},{"Id":389080,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"00409014411"},{"Id":389081,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"00409014421"},{"Id":389082,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"00409015201"},{"Id":389083,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"00409015224"},{"Id":389084,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00409022201"},{"Id":389085,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00409022210"},{"Id":389086,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"00409082901"},{"Id":389087,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"00409082911"},{"Id":389088,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"00409083001"},{"Id":389089,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"00409083011"},{"Id":389090,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"00409114102"},{"Id":389091,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"00409114112"},{"Id":389092,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409114402"},{"Id":389093,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409114405"},{"Id":389094,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409114410"},{"Id":389095,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409114411"},{"Id":389096,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409114462"},{"Id":389097,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409114465"},{"Id":389098,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"00409120703"},{"Id":389099,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"00409120713"},{"Id":389100,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"00409121501"},{"Id":389101,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"00409121521"},{"Id":389102,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00409128303"},{"Id":389103,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00409128317"},{"Id":389104,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00409128331"},{"Id":389105,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00409128337"},{"Id":389106,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102020","GenericName":"HYDROMORPHONE HCL INJ 4 MG/ML","NDC":"00409130403"},{"Id":389107,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102020","GenericName":"HYDROMORPHONE HCL INJ 4 MG/ML","NDC":"00409130431"},{"Id":389108,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00409131203"},{"Id":389109,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00409131216"},{"Id":389110,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00409131230"},{"Id":389111,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00409131236"},{"Id":389112,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"00409131611"},{"Id":389113,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"00409131632"},{"Id":389114,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"00409131901"},{"Id":389115,"FormularyType":"OHP","DrugName":"LIDOCAINE INJ 20MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3520002010E532","GenericName":"LIDOCAINE HCL(CARDIAC) IV PF SOLN PREF SYR 100 MG/5ML (2%)","NDC":"00409132305"},{"Id":389116,"FormularyType":"OHP","DrugName":"LIDOCAINE INJ 20MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3520002010E532","GenericName":"LIDOCAINE HCL(CARDIAC) IV PF SOLN PREF SYR 100 MG/5ML (2%)","NDC":"00409132315"},{"Id":389117,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00409139021"},{"Id":389118,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00409139051"},{"Id":389119,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00409139121"},{"Id":389120,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00409139122"},{"Id":389121,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00409140212"},{"Id":389122,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00409140227"},{"Id":389123,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 25%","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002030","GenericName":"DEXTROSE INJ 25%","NDC":"00409177510"},{"Id":389124,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 25%","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002030","GenericName":"DEXTROSE INJ 25%","NDC":"00409177540"},{"Id":389125,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOCT - Soln Cartridge","Strength":"0.4","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E210","GenericName":"NALOXONE HCL SOLN CARTRIDGE 0.4 MG/ML","NDC":"00409178203"},{"Id":389126,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOCT - Soln Cartridge","Strength":"0.4","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E210","GenericName":"NALOXONE HCL SOLN CARTRIDGE 0.4 MG/ML","NDC":"00409178269"},{"Id":389127,"FormularyType":"OHP","DrugName":"HYDROMORPHON SOL 0.25/0.5","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102001","GenericName":"HYDROMORPHONE HCL INJ 0.5 MG/ML","NDC":"00409180501"},{"Id":389128,"FormularyType":"OHP","DrugName":"HYDROMORPHON SOL 0.25/0.5","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102001","GenericName":"HYDROMORPHONE HCL INJ 0.5 MG/ML","NDC":"00409180510"},{"Id":389129,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102049","GenericName":"MORPHINE SULFATE IV SOLN 50 MG/ML","NDC":"00409189620"},{"Id":389130,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"00409190201"},{"Id":389131,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"00409190211"},{"Id":389132,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00409198503"},{"Id":389133,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00409198530"},{"Id":389134,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102049","GenericName":"MORPHINE SULFATE IV SOLN 50 MG/ML","NDC":"00409202201"},{"Id":389135,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"00409222001"},{"Id":389136,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"00409222024"},{"Id":389137,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 200MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112024","GenericName":"CIPROFLOXACIN 200 MG/100ML IN D5W","NDC":"00409230001"},{"Id":389138,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 200MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112024","GenericName":"CIPROFLOXACIN 200 MG/100ML IN D5W","NDC":"00409230024"},{"Id":389139,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102009","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/5ML (BASE EQUIVALENT)","NDC":"00409230504"},{"Id":389140,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102009","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/5ML (BASE EQUIVALENT)","NDC":"00409230505"},{"Id":389141,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102009","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/5ML (BASE EQUIVALENT)","NDC":"00409230550"},{"Id":389142,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102009","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/5ML (BASE EQUIVALENT)","NDC":"00409230555"},{"Id":389143,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102006","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/ML (BASE EQUIVALENT)","NDC":"00409230801"},{"Id":389144,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102011","GenericName":"MIDAZOLAM HCL INJ PF 10 MG/2ML (BASE EQUIVALENT)","NDC":"00409230802"},{"Id":389145,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102006","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/ML (BASE EQUIVALENT)","NDC":"00409230821"},{"Id":389146,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102011","GenericName":"MIDAZOLAM HCL INJ PF 10 MG/2ML (BASE EQUIVALENT)","NDC":"00409230822"},{"Id":389147,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102006","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/ML (BASE EQUIVALENT)","NDC":"00409230849"},{"Id":389148,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102011","GenericName":"MIDAZOLAM HCL INJ PF 10 MG/2ML (BASE EQUIVALENT)","NDC":"00409230850"},{"Id":389149,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102006","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/ML (BASE EQUIVALENT)","NDC":"00409230869"},{"Id":389150,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102117","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 1 GM","NDC":"00409258501"},{"Id":389151,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102117","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 1 GM","NDC":"00409258511"},{"Id":389152,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00409259605"},{"Id":389153,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00409259615"},{"Id":389154,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00409263401"},{"Id":389155,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00409263405"},{"Id":389156,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00409263410"},{"Id":389157,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00409263425"},{"Id":389158,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 500/50ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00409263450"},{"Id":389159,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252112","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 1.5 (1-0.5) GM","NDC":"00409268901"},{"Id":389160,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252112","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 1.5 (1-0.5) GM","NDC":"00409268921"},{"Id":389161,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00409272001"},{"Id":389162,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00409272002"},{"Id":389163,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00409272003"},{"Id":389164,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00409272030"},{"Id":389165,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00409272031"},{"Id":389166,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00409272032"},{"Id":389167,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"00409272101"},{"Id":389168,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"00409272130"},{"Id":389169,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00409272301"},{"Id":389170,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00409272302"},{"Id":389171,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00409272330"},{"Id":389172,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00409272331"},{"Id":389173,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252122","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 3 (2-1) GM","NDC":"00409298703"},{"Id":389174,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252122","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 3 (2-1) GM","NDC":"00409298723"},{"Id":389175,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 12-1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702150","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 13.5 GM (12-1.5 GM)","NDC":"00409299914"},{"Id":389176,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409329415"},{"Id":389177,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409329425"},{"Id":389178,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409329451"},{"Id":389179,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409329461"},{"Id":389180,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 400MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112028","GenericName":"CIPROFLOXACIN 400 MG/200ML IN D5W","NDC":"00409330001"},{"Id":389181,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 400MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112028","GenericName":"CIPROFLOXACIN 400 MG/200ML IN D5W","NDC":"00409330024"},{"Id":389182,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"00409333001"},{"Id":389183,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"00409333024"},{"Id":389184,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00409336510"},{"Id":389185,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"00409338310"},{"Id":389186,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"00409338311"},{"Id":389187,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"00409338511"},{"Id":389188,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"00409338515"},{"Id":389189,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"00409339010"},{"Id":389190,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"00409339011"},{"Id":389191,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00409341201"},{"Id":389192,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00409341210"},{"Id":389193,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00409341401"},{"Id":389194,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00409341411"},{"Id":389195,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00409341418"},{"Id":389196,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00409341421"},{"Id":389197,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"00409343501"},{"Id":389198,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"00409343524"},{"Id":389199,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"00409351021"},{"Id":389200,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"00409351022"},{"Id":389201,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"00409351501"},{"Id":389202,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"00409351511"},{"Id":389203,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 80MG/2ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"00409357801"},{"Id":389204,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 80MG/2ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"00409357811"},{"Id":389205,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409401101"},{"Id":389206,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409401161"},{"Id":389207,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 0.5/0.5","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00409426401"},{"Id":389208,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 0.5/0.5","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00409426411"},{"Id":389209,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"00409432101"},{"Id":389210,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"00409432124"},{"Id":389211,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"00409433201"},{"Id":389212,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"00409433211"},{"Id":389213,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"00409444401"},{"Id":389214,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"00409444424"},{"Id":389215,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040102040","GenericName":"LINEZOLID IN SODIUM CHLORIDE IV SOLN 600 MG/300ML-0.9%","NDC":"00409488303"},{"Id":389216,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040102040","GenericName":"LINEZOLID IN SODIUM CHLORIDE IV SOLN 600 MG/300ML-0.9%","NDC":"00409488310"},{"Id":389217,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488710"},{"Id":389218,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488717"},{"Id":389219,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488720"},{"Id":389220,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488723"},{"Id":389221,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488724"},{"Id":389222,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488725"},{"Id":389223,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488750"},{"Id":389224,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00409488799"},{"Id":389225,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488801"},{"Id":389226,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488802"},{"Id":389227,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488803"},{"Id":389228,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488806"},{"Id":389229,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488810"},{"Id":389230,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488812"},{"Id":389231,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488820"},{"Id":389232,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00409488850"},{"Id":389233,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"00409501701"},{"Id":389234,"FormularyType":"OHP","DrugName":"TAZICEF INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002110","GenericName":"CEFTAZIDIME FOR INJ 1 GM","NDC":"00409508211"},{"Id":389235,"FormularyType":"OHP","DrugName":"TAZICEF INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002110","GenericName":"CEFTAZIDIME FOR INJ 1 GM","NDC":"00409508216"},{"Id":389236,"FormularyType":"OHP","DrugName":"TAZICEF INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002117","GenericName":"CEFTAZIDIME FOR IV SOLN 2 GM","NDC":"00409508411"},{"Id":389237,"FormularyType":"OHP","DrugName":"TAZICEF INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002117","GenericName":"CEFTAZIDIME FOR IV SOLN 2 GM","NDC":"00409508413"},{"Id":389238,"FormularyType":"OHP","DrugName":"TAZICEF INJ 6GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"6","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002122","GenericName":"CEFTAZIDIME FOR IV SOLN 6 GM","NDC":"00409508611"},{"Id":389239,"FormularyType":"OHP","DrugName":"TAZICEF INJ 6GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"6","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002122","GenericName":"CEFTAZIDIME FOR IV SOLN 6 GM","NDC":"00409508613"},{"Id":389240,"FormularyType":"OHP","DrugName":"TAZICEF INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002112","GenericName":"CEFTAZIDIME FOR IV SOLN 1 GM","NDC":"00409509211"},{"Id":389241,"FormularyType":"OHP","DrugName":"TAZICEF INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002112","GenericName":"CEFTAZIDIME FOR IV SOLN 1 GM","NDC":"00409509216"},{"Id":389242,"FormularyType":"OHP","DrugName":"TAZICEF INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002117","GenericName":"CEFTAZIDIME FOR IV SOLN 2 GM","NDC":"00409509311"},{"Id":389243,"FormularyType":"OHP","DrugName":"TAZICEF INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002117","GenericName":"CEFTAZIDIME FOR IV SOLN 2 GM","NDC":"00409509314"},{"Id":389244,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00409525510"},{"Id":389245,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00409525515"},{"Id":389246,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"00409555501"},{"Id":389247,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"00409555502"},{"Id":389248,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"00409555511"},{"Id":389249,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"00409555512"},{"Id":389250,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610202"},{"Id":389251,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610204"},{"Id":389252,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610210"},{"Id":389253,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610218"},{"Id":389254,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610219"},{"Id":389255,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610220"},{"Id":389256,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610225"},{"Id":389257,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610226"},{"Id":389258,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610227"},{"Id":389259,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610235"},{"Id":389260,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610236"},{"Id":389261,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"00409610237"},{"Id":389262,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"00409650901"},{"Id":389263,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"00409650949"},{"Id":389264,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"00409653101"},{"Id":389265,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"00409653102"},{"Id":389266,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"00409653111"},{"Id":389267,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"00409653112"},{"Id":389268,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00409653311"},{"Id":389269,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00409653321"},{"Id":389270,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00409653331"},{"Id":389271,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00409653359"},{"Id":389272,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"00409653401"},{"Id":389273,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"00409653411"},{"Id":389274,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00409653501"},{"Id":389275,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"00409653511"},{"Id":389276,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102010","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML","NDC":"00409655701"},{"Id":389277,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00409656201"},{"Id":389278,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00409656220"},{"Id":389279,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"00409662514"},{"Id":389280,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"00409662522"},{"Id":389281,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"00409662530"},{"Id":389282,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"00409662535"},{"Id":389283,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00409663501"},{"Id":389284,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00409663518"},{"Id":389285,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 50%","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"00409664802"},{"Id":389286,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 50%","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"00409664816"},{"Id":389287,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00409665106"},{"Id":389288,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00409665119"},{"Id":389289,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00409665305"},{"Id":389290,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"00409665318"},{"Id":389291,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 2.5/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002050","GenericName":"SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","NDC":"00409666001"},{"Id":389292,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 2.5/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002050","GenericName":"SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","NDC":"00409666075"},{"Id":389293,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00409710002"},{"Id":389294,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00409710004"},{"Id":389295,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00409710066"},{"Id":389296,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00409710067"},{"Id":389297,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00409710068"},{"Id":389298,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00409710069"},{"Id":389299,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00409710102"},{"Id":389300,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00409710104"},{"Id":389301,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00409710166"},{"Id":389302,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00409710167"},{"Id":389303,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00409710168"},{"Id":389304,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00409710169"},{"Id":389305,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00409733201"},{"Id":389306,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00409733211"},{"Id":389307,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00409733220"},{"Id":389308,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00409733221"},{"Id":389309,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102117","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 1 GM","NDC":"00409733304"},{"Id":389310,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102117","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 1 GM","NDC":"00409733311"},{"Id":389311,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102117","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 1 GM","NDC":"00409733331"},{"Id":389312,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102117","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 1 GM","NDC":"00409733349"},{"Id":389313,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102125","GenericName":"CEFTRIAXONE SODIUM FOR INJ 10 GM","NDC":"00409733410"},{"Id":389314,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102125","GenericName":"CEFTRIAXONE SODIUM FOR INJ 10 GM","NDC":"00409733420"},{"Id":389315,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00409733503"},{"Id":389316,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00409733513"},{"Id":389317,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00409733520"},{"Id":389318,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00409733521"},{"Id":389319,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102122","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 2 GM","NDC":"00409733604"},{"Id":389320,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102122","GenericName":"CEFTRIAXONE SODIUM FOR IV SOLN 2 GM","NDC":"00409733611"},{"Id":389321,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00409733701"},{"Id":389322,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00409733711"},{"Id":389323,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00409733720"},{"Id":389324,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00409733721"},{"Id":389325,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00409733801"},{"Id":389326,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00409733811"},{"Id":389327,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00409733820"},{"Id":389328,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00409733821"},{"Id":389329,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 50%","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"00409751716"},{"Id":389330,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 50%","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"O","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"00409751766"},{"Id":389331,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409818301"},{"Id":389332,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409818311"},{"Id":389333,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409818315"},{"Id":389334,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"00409818325"},{"Id":389335,"FormularyType":"OHP","DrugName":"CEFEPIME HCL INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"00409956601"},{"Id":389336,"FormularyType":"OHP","DrugName":"CEFEPIME HCL INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"00409956610"},{"Id":389337,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409963305"},{"Id":389338,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"00409963365"},{"Id":389339,"FormularyType":"OHP","DrugName":"CEFEPIME HCL INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"00409973501"},{"Id":389340,"FormularyType":"OHP","DrugName":"CEFEPIME HCL INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"00409973510"},{"Id":389341,"FormularyType":"OHP","DrugName":"LO LOESTRIN TAB 1-10-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991003500320","GenericName":"NORETHIN-ETH ESTRADIOL-FE TAB 1 MG-10 MCG (24)/10 MCG (2)","NDC":"00430042014"},{"Id":389342,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"00456045701"},{"Id":389343,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"00456045801"},{"Id":389344,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"00456045901"},{"Id":389345,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"00456046001"},{"Id":389346,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"00456046101"},{"Id":389347,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000330","GenericName":"THYROID TAB 180 MG (3 GRAIN)","NDC":"00456046201"},{"Id":389348,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000335","GenericName":"THYROID TAB 240 MG (4 GRAIN)","NDC":"00456046301"},{"Id":389349,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000340","GenericName":"THYROID TAB 300 MG (5 GRAIN)","NDC":"00456046401"},{"Id":389350,"FormularyType":"OHP","DrugName":"ARMOUR THYRO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"00456104501"},{"Id":389351,"FormularyType":"OHP","DrugName":"XTANDI CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402430000120","GenericName":"ENZALUTAMIDE CAP 40 MG","NDC":"00469012599"},{"Id":389352,"FormularyType":"OHP","DrugName":"XTANDI TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402430000320","GenericName":"ENZALUTAMIDE TAB 40 MG","NDC":"00469062599"},{"Id":389353,"FormularyType":"OHP","DrugName":"XTANDI TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402430000340","GenericName":"ENZALUTAMIDE TAB 80 MG","NDC":"00469072560"},{"Id":389354,"FormularyType":"OHP","DrugName":"XOSPATA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533020200320","GenericName":"GILTERITINIB FUMARATE TABLET 40 MG (BASE EQUIVALENT)","NDC":"00469142590"},{"Id":389355,"FormularyType":"OHP","DrugName":"GRISEOFULVIN SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000030101805","GenericName":"GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML","NDC":"00472001304"},{"Id":389356,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"00472008216"},{"Id":389357,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"00472016615"},{"Id":389358,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"00472016630"},{"Id":389359,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00472023516"},{"Id":389360,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE DIPROP","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"00472037915"},{"Id":389361,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE DIPROP","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"00472037945"},{"Id":389362,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"00472038015"},{"Id":389363,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"00472038045"},{"Id":389364,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"00472038115"},{"Id":389365,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"00472038145"},{"Id":389366,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00472200216"},{"Id":389367,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00472200294"},{"Id":389368,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"00480008305"},{"Id":389369,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 0.5GM","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100110","GenericName":"ICOSAPENT ETHYL CAP 0.5 GM","NDC":"00480012649"},{"Id":389370,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"00480012789"},{"Id":389371,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"00480124128"},{"Id":389372,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"00480124228"},{"Id":389373,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"00480124328"},{"Id":389374,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"00480124421"},{"Id":389375,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"00480124521"},{"Id":389376,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"00480124621"},{"Id":389377,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 11.25-69","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307040","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 11.25-69 MG","NDC":"00480229956"},{"Id":389378,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000120","GenericName":"POMALIDOMIDE CAP 3 MG","NDC":"00480260121"},{"Id":389379,"FormularyType":"OHP","DrugName":"LAPATINIB TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533026100320","GenericName":"LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV)","NDC":"00480323751"},{"Id":389380,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 15-92MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307050","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 15-92 MG","NDC":"00480329556"},{"Id":389381,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 7.5-46MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307030","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 7.5-46 MG","NDC":"00480329656"},{"Id":389382,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 3.75-23","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307020","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 3.75-23 MG","NDC":"00480329756"},{"Id":389383,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"00480330901"},{"Id":389384,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"00480331001"},{"Id":389385,"FormularyType":"OHP","DrugName":"AMETHYST TAB 90-20MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25994002350320","GenericName":"LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","NDC":"00480347224"},{"Id":389386,"FormularyType":"OHP","DrugName":"NORA-BE TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"00480347516"},{"Id":389387,"FormularyType":"OHP","DrugName":"NORA-BE TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"00480347519"},{"Id":389388,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"00480347819"},{"Id":389389,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"00480347868"},{"Id":389390,"FormularyType":"OHP","DrugName":"CRYSELLE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"00480349316"},{"Id":389391,"FormularyType":"OHP","DrugName":"CRYSELLE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"00480349324"},{"Id":389392,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"00480349405"},{"Id":389393,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"00480349505"},{"Id":389394,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"00480352356"},{"Id":389395,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"00480352456"},{"Id":389396,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"00480356401"},{"Id":389397,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"00480356501"},{"Id":389398,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"00480356601"},{"Id":389399,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"00480356701"},{"Id":389400,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"00480356801"},{"Id":389401,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"00480356901"},{"Id":389402,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"00480357001"},{"Id":389403,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"00480361087"},{"Id":389404,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"00480361198"},{"Id":389405,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"00480366720"},{"Id":389406,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"00480366722"},{"Id":389407,"FormularyType":"OHP","DrugName":"VESTURA TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"00480400028"},{"Id":389408,"FormularyType":"OHP","DrugName":"VESTURA TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"00480400062"},{"Id":389409,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000110","GenericName":"POMALIDOMIDE CAP 1 MG","NDC":"00480401821"},{"Id":389410,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000115","GenericName":"POMALIDOMIDE CAP 2 MG","NDC":"00480402221"},{"Id":389411,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000125","GenericName":"POMALIDOMIDE CAP 4 MG","NDC":"00480403521"},{"Id":389412,"FormularyType":"OHP","DrugName":"GEFITINIB TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360030000320","GenericName":"GEFITINIB TAB 250 MG","NDC":"00480405356"},{"Id":389413,"FormularyType":"OHP","DrugName":"PAZOPANIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533042100320","GenericName":"PAZOPANIB HCL TAB 200 MG (BASE EQUIV)","NDC":"00480418489"},{"Id":389414,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"00480510106"},{"Id":389415,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"00480510206"},{"Id":389416,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"00480510306"},{"Id":389417,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"00480510456"},{"Id":389418,"FormularyType":"OHP","DrugName":"SORAFENIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533060400320","GenericName":"SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"00480542589"},{"Id":389419,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 125MG","DosageForm":"TBSO - Tablet Soluble","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007320","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 125 MG","NDC":"00480701156"},{"Id":389420,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 250MG","DosageForm":"TBSO - Tablet Soluble","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007330","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 250 MG","NDC":"00480701256"},{"Id":389421,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 500MG","DosageForm":"TBSO - Tablet Soluble","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007340","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 500 MG","NDC":"00480701356"},{"Id":389422,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"00480716710"},{"Id":389423,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00480716810"},{"Id":389424,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 800MG DR","DosageForm":"TBEC - Tablet DR","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000650","GenericName":"MESALAMINE TAB DELAYED RELEASE 800 MG","NDC":"00480775080"},{"Id":389425,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"00480782056"},{"Id":389426,"FormularyType":"OHP","DrugName":"PROPYLTHIOUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300020000310","GenericName":"PROPYLTHIOURACIL TAB 50 MG","NDC":"00480924201"},{"Id":389427,"FormularyType":"OHP","DrugName":"ALYQ TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"00480927706"},{"Id":389428,"FormularyType":"OHP","DrugName":"ED-APAP LIQ 80MG/2.5","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"00485005708"},{"Id":389429,"FormularyType":"OHP","DrugName":"ED CHLORPED SYP JR","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020151205","GenericName":"CHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML","NDC":"00485009816"},{"Id":389430,"FormularyType":"OHP","DrugName":"K-PHOS TAB","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"PHOSPHATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79600010020305","GenericName":"POTASSIUM PHOSPHATE MONOBASIC TAB 500 MG","NDC":"00486111101"},{"Id":389431,"FormularyType":"OHP","DrugName":"K-PHOS TAB","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"PHOSPHATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79600010020305","GenericName":"POTASSIUM PHOSPHATE MONOBASIC TAB 500 MG","NDC":"00486111105"},{"Id":389432,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00487020101"},{"Id":389433,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00487020103"},{"Id":389434,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"00487020160"},{"Id":389435,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"00487030101"},{"Id":389436,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00487430105"},{"Id":389437,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00487430110"},{"Id":389438,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00487430150"},{"Id":389439,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00487610501"},{"Id":389440,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 3%","DosageForm":"NEBU - Nebulization solution","Strength":"3","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002530","GenericName":"SODIUM CHLORIDE SOLN NEBU 3%","NDC":"00487900330"},{"Id":389441,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 7%","DosageForm":"NEBU - Nebulization solution","Strength":"7","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002535","GenericName":"SODIUM CHLORIDE SOLN NEBU 7%","NDC":"00487900730"},{"Id":389442,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"00487930103"},{"Id":389443,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"00487930133"},{"Id":389444,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"00487930201"},{"Id":389445,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00487950101"},{"Id":389446,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00487950103"},{"Id":389447,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00487950125"},{"Id":389448,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"00487950160"},{"Id":389449,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00487960101"},{"Id":389450,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00487960130"},{"Id":389451,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00487970101"},{"Id":389452,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00487970130"},{"Id":389453,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00487980101"},{"Id":389454,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00487980125"},{"Id":389455,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00487980130"},{"Id":389456,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00487980160"},{"Id":389457,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.5%","DosageForm":"NEBU - Nebulization solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102520","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)","NDC":"00487990130"},{"Id":389458,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"00487990401"},{"Id":389459,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"00487990425"},{"Id":389460,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00517003101"},{"Id":389461,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00517003125"},{"Id":389462,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00517003201"},{"Id":389463,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00517003225"},{"Id":389464,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"00517013001"},{"Id":389465,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 20MG/ML","DosageForm":"OIL - Oil","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201710","GenericName":"ESTRADIOL VALERATE IM IN OIL 20 MG/ML","NDC":"00517042001"},{"Id":389466,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 40MG/ML","DosageForm":"OIL - Oil","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201715","GenericName":"ESTRADIOL VALERATE IM IN OIL 40 MG/ML","NDC":"00517044001"},{"Id":389467,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00517183001"},{"Id":389468,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00517301001"},{"Id":389469,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00517301025"},{"Id":389470,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00517302001"},{"Id":389471,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00517302025"},{"Id":389472,"FormularyType":"OHP","DrugName":"NITROGLYCER INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030002020","GenericName":"NITROGLYCERIN IV SOLN 5 MG/ML","NDC":"00517481025"},{"Id":389473,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00527058601"},{"Id":389474,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00527058610"},{"Id":389475,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"00527076037"},{"Id":389476,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"00527076137"},{"Id":389477,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"00527076237"},{"Id":389478,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"00527076337"},{"Id":389479,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"00527076437"},{"Id":389480,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"00527076537"},{"Id":389481,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"00527076637"},{"Id":389482,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"00527079037"},{"Id":389483,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"00527079137"},{"Id":389484,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"00527079237"},{"Id":389485,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"00527079337"},{"Id":389486,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"00527079437"},{"Id":389487,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"00527079537"},{"Id":389488,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"00527123101"},{"Id":389489,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"00527123110"},{"Id":389490,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00527128201"},{"Id":389491,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00527128210"},{"Id":389492,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"00527130101"},{"Id":389493,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"00527130105"},{"Id":389494,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"00527131101"},{"Id":389495,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"00527131301"},{"Id":389496,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"00527131801"},{"Id":389497,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"00527132601"},{"Id":389498,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00527133001"},{"Id":389499,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00527133010"},{"Id":389500,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"00527133301"},{"Id":389501,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000305","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 50 MG","NDC":"00527133501"},{"Id":389502,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00527133701"},{"Id":389503,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00527133705"},{"Id":389504,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00527133710"},{"Id":389505,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"00527133825"},{"Id":389506,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"00527133850"},{"Id":389507,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"00527136701"},{"Id":389508,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"00527136710"},{"Id":389509,"FormularyType":"OHP","DrugName":"DANAZOL CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000110","GenericName":"DANAZOL CAP 100 MG","NDC":"00527136801"},{"Id":389510,"FormularyType":"OHP","DrugName":"DANAZOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000115","GenericName":"DANAZOL CAP 200 MG","NDC":"00527136901"},{"Id":389511,"FormularyType":"OHP","DrugName":"DANAZOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000115","GenericName":"DANAZOL CAP 200 MG","NDC":"00527136906"},{"Id":389512,"FormularyType":"OHP","DrugName":"DANAZOL CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000105","GenericName":"DANAZOL CAP 50 MG","NDC":"00527139201"},{"Id":389513,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100320","GenericName":"PILOCARPINE HCL TAB 7.5 MG","NDC":"00527140701"},{"Id":389514,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"00527141901"},{"Id":389515,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"00527141910"},{"Id":389516,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"00527163201"},{"Id":389517,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"00527163210"},{"Id":389518,"FormularyType":"OHP","DrugName":"CODEINE SULF TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100020200310","GenericName":"CODEINE SULFATE TAB 30 MG","NDC":"00527169801"},{"Id":389519,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 5MG/ACT","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002010","GenericName":"SUMATRIPTAN NASAL SPRAY 5 MG/ACT","NDC":"00527181843"},{"Id":389520,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"00527183037"},{"Id":389521,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 20MG/ACT","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002040","GenericName":"SUMATRIPTAN NASAL SPRAY 20 MG/ACT","NDC":"00527185943"},{"Id":389522,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010007520","GenericName":"CLARITHROMYCIN TAB ER 24HR 500 MG","NDC":"00527193006"},{"Id":389523,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000310","GenericName":"CLARITHROMYCIN TAB 250 MG","NDC":"00527193106"},{"Id":389524,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"00527193206"},{"Id":389525,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN SOL 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002050","GenericName":"LEVOFLOXACIN ORAL SOLN 25 MG/ML","NDC":"00527194866"},{"Id":389526,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN SOL 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002050","GenericName":"LEVOFLOXACIN ORAL SOLN 25 MG/ML","NDC":"00527194868"},{"Id":389527,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN SOL 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002050","GenericName":"LEVOFLOXACIN ORAL SOLN 25 MG/ML","NDC":"00527194870"},{"Id":389528,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"00527213335"},{"Id":389529,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"00527224432"},{"Id":389530,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"00527224832"},{"Id":389531,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"00527237020"},{"Id":389532,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"00527237032"},{"Id":389533,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"00527239519"},{"Id":389534,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"00527242532"},{"Id":389535,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"00527242546"},{"Id":389536,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"00527242632"},{"Id":389537,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"00527242646"},{"Id":389538,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"00527242732"},{"Id":389539,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"00527242746"},{"Id":389540,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"00527260037"},{"Id":389541,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"00527260043"},{"Id":389542,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"00527260137"},{"Id":389543,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"00527260143"},{"Id":389544,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"00527260237"},{"Id":389545,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"00527260243"},{"Id":389546,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"00527260337"},{"Id":389547,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"00527260343"},{"Id":389548,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"00527301248"},{"Id":389549,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00527328043"},{"Id":389550,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00527328046"},{"Id":389551,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00527328143"},{"Id":389552,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00527328146"},{"Id":389553,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00527328243"},{"Id":389554,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00527328246"},{"Id":389555,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00527328343"},{"Id":389556,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00527328346"},{"Id":389557,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00527328443"},{"Id":389558,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00527328446"},{"Id":389559,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00527328543"},{"Id":389560,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00527328546"},{"Id":389561,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00527328643"},{"Id":389562,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00527328646"},{"Id":389563,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"00527328743"},{"Id":389564,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"00527328746"},{"Id":389565,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00527328843"},{"Id":389566,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00527328846"},{"Id":389567,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00527328943"},{"Id":389568,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00527328946"},{"Id":389569,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00527329043"},{"Id":389570,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"00527329046"},{"Id":389571,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"00527329146"},{"Id":389572,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"00527410737"},{"Id":389573,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"00527410837"},{"Id":389574,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 60MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107025","GenericName":"PROPRANOLOL HCL CAP ER 24HR 60 MG","NDC":"00527411637"},{"Id":389575,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 80MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107030","GenericName":"PROPRANOLOL HCL CAP ER 24HR 80 MG","NDC":"00527411737"},{"Id":389576,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107035","GenericName":"PROPRANOLOL HCL CAP ER 24HR 120 MG","NDC":"00527411837"},{"Id":389577,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 160MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107040","GenericName":"PROPRANOLOL HCL CAP ER 24HR 160 MG","NDC":"00527411937"},{"Id":389578,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 10MG CD","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100210","GenericName":"METHYLPHENIDATE HCL CAP ER 10 MG (CD)","NDC":"00527457937"},{"Id":389579,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 20MG CD","DosageForm":"CPCR - Capsule ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100220","GenericName":"METHYLPHENIDATE HCL CAP ER 20 MG (CD)","NDC":"00527458037"},{"Id":389580,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 30MG CD","DosageForm":"CPCR - Capsule ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100230","GenericName":"METHYLPHENIDATE HCL CAP ER 30 MG (CD)","NDC":"00527458137"},{"Id":389581,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 40MG CD","DosageForm":"CPCR - Capsule ER","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100240","GenericName":"METHYLPHENIDATE HCL CAP ER 40 MG (CD)","NDC":"00527458237"},{"Id":389582,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 50MG CD","DosageForm":"CPCR - Capsule ER","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100250","GenericName":"METHYLPHENIDATE HCL CAP ER 50 MG (CD)","NDC":"00527458337"},{"Id":389583,"FormularyType":"OHP","DrugName":"METHYLPHENID CAP 60MG CD","DosageForm":"CPCR - Capsule ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100260","GenericName":"METHYLPHENIDATE HCL CAP ER 60 MG (CD)","NDC":"00527458437"},{"Id":389584,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"00527459113"},{"Id":389585,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"00527459213"},{"Id":389586,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"00527459313"},{"Id":389587,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"00527466137"},{"Id":389588,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"00527466237"},{"Id":389589,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"00527466337"},{"Id":389590,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"00527466437"},{"Id":389591,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"00527466537"},{"Id":389592,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"00527466637"},{"Id":389593,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"00527466737"},{"Id":389594,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00527512070"},{"Id":389595,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00527512078"},{"Id":389596,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00527512570"},{"Id":389597,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"00527512578"},{"Id":389598,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"00527513762"},{"Id":389599,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"00527516082"},{"Id":389600,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"00527540668"},{"Id":389601,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"00527540670"},{"Id":389602,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"00527600480"},{"Id":389603,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107020","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","NDC":"00527810637"},{"Id":389604,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107030","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","NDC":"00527810737"},{"Id":389605,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107035","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","NDC":"00527810837"},{"Id":389606,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107040","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","NDC":"00527810937"},{"Id":389607,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107045","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","NDC":"00527811037"},{"Id":389608,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107050","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","NDC":"00527811137"},{"Id":389609,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 35MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107055","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","NDC":"00527811237"},{"Id":389610,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 40MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107060","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 40 MG","NDC":"00527811337"},{"Id":389611,"FormularyType":"OHP","DrugName":"ALLER-CHLOR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"00536100610"},{"Id":389612,"FormularyType":"OHP","DrugName":"CAL-GEST CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"00536100715"},{"Id":389613,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00536100836"},{"Id":389614,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00536100901"},{"Id":389615,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"00536104710"},{"Id":389616,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"00536104815"},{"Id":389617,"FormularyType":"OHP","DrugName":"CALC ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00536104922"},{"Id":389618,"FormularyType":"OHP","DrugName":"CALC ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"00536105022"},{"Id":389619,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00536105224"},{"Id":389620,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00536105227"},{"Id":389621,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00536105260"},{"Id":389622,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00536105284"},{"Id":389623,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"00536105429"},{"Id":389624,"FormularyType":"OHP","DrugName":"ACNE MEDICAT GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004010","GenericName":"BENZOYL PEROXIDE GEL 5%","NDC":"00536105556"},{"Id":389625,"FormularyType":"OHP","DrugName":"ACNE MEDICAT GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"00536105656"},{"Id":389626,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"00536110301"},{"Id":389627,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00536110688"},{"Id":389628,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00536110788"},{"Id":389629,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00536110888"},{"Id":389630,"FormularyType":"OHP","DrugName":"UREA 20 INTN CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"00536110945"},{"Id":389631,"FormularyType":"OHP","DrugName":"ARTH PAIN CRE 0.075%","DosageForm":"CREA - Cream","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003730","GenericName":"CAPSAICIN CREAM 0.075%","NDC":"00536111825"},{"Id":389632,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"00536114730"},{"Id":389633,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00536117201"},{"Id":389634,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB 648MG","DosageForm":"TABS - Tablet","Strength":"648","BrandVsGeneric":"N","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000309","GenericName":"CALCIUM CARBONATE (ANTACID) TAB 648 MG","NDC":"00536120610"},{"Id":389635,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00536121429"},{"Id":389636,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"00536123201"},{"Id":389637,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00536123441"},{"Id":389638,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00536123981"},{"Id":389639,"FormularyType":"OHP","DrugName":"SENEXON-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00536124701"},{"Id":389640,"FormularyType":"OHP","DrugName":"SENEXON-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00536124710"},{"Id":389641,"FormularyType":"OHP","DrugName":"STIMULANT LX TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00536124801"},{"Id":389642,"FormularyType":"OHP","DrugName":"STIMULANT LX TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00536124810"},{"Id":389643,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"00536125240"},{"Id":389644,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"00536125628"},{"Id":389645,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"00536125919"},{"Id":389646,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"00536125963"},{"Id":389647,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 10% WASH","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"00536126163"},{"Id":389648,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"00536126328"},{"Id":389649,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"00536126456"},{"Id":389650,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00536126511"},{"Id":389651,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00536126526"},{"Id":389652,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"00536126595"},{"Id":389653,"FormularyType":"OHP","DrugName":"SENNA LIQ 8.8/5ML","DosageForm":"LIQD - Liquid","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"00536126659"},{"Id":389654,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00536129229"},{"Id":389655,"FormularyType":"OHP","DrugName":"ANTACID SUS REG ST","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00536129383"},{"Id":389656,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00536129434"},{"Id":389657,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"00536129497"},{"Id":389658,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00536129801"},{"Id":389659,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"00536129901"},{"Id":389660,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"00536129910"},{"Id":389661,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00536130485"},{"Id":389662,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"00536130723"},{"Id":389663,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"00536131625"},{"Id":389664,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"00536131628"},{"Id":389665,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"00536131698"},{"Id":389666,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00536131783"},{"Id":389667,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00536131983"},{"Id":389668,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00536132197"},{"Id":389669,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB PLUS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"00536132601"},{"Id":389670,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"00536132701"},{"Id":389671,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"00536132706"},{"Id":389672,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"00536132710"},{"Id":389673,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00536133709"},{"Id":389674,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"00536133735"},{"Id":389675,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00536133809"},{"Id":389676,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"00536133835"},{"Id":389677,"FormularyType":"OHP","DrugName":"VITAMIN D DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"00536134380"},{"Id":389678,"FormularyType":"OHP","DrugName":"IRON INF/TOD DRO 15MG","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"00536134480"},{"Id":389679,"FormularyType":"OHP","DrugName":"MULTIV INFAN DRO /TODDLER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"00536134580"},{"Id":389680,"FormularyType":"OHP","DrugName":"MULTI/IRON/ DRO INF/TODD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"00536134680"},{"Id":389681,"FormularyType":"OHP","DrugName":"VITAMI A-C-D DRO INF/TODD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002019","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 250 MCG-10 MCG-50MG/ML***","NDC":"00536134780"},{"Id":389682,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"00536135301"},{"Id":389683,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536136206"},{"Id":389684,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536136223"},{"Id":389685,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536136234"},{"Id":389686,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"00536136601"},{"Id":389687,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"00536136707"},{"Id":389688,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536137206"},{"Id":389689,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536137223"},{"Id":389690,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536137234"},{"Id":389691,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"00536137575"},{"Id":389692,"FormularyType":"OHP","DrugName":"MELATONIN QD TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"00536139708"},{"Id":389693,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"00536140085"},{"Id":389694,"FormularyType":"OHP","DrugName":"ORALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00536140117"},{"Id":389695,"FormularyType":"OHP","DrugName":"ORALYTE SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00536140317"},{"Id":389696,"FormularyType":"OHP","DrugName":"ORALYTE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00536140517"},{"Id":389697,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"00536140795"},{"Id":389698,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"00536141220"},{"Id":389699,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"00536141226"},{"Id":389700,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00536141347"},{"Id":389701,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00536141348"},{"Id":389702,"FormularyType":"OHP","DrugName":"NEPHRO-VITE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"00536141501"},{"Id":389703,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"00536141638"},{"Id":389704,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00536142677"},{"Id":389705,"FormularyType":"OHP","DrugName":"LEVONORGESTR TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"00536143363"},{"Id":389706,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"00536144540"},{"Id":389707,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"00536145684"},{"Id":389708,"FormularyType":"OHP","DrugName":"ACNE MEDICAT GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"00536145925"},{"Id":389709,"FormularyType":"OHP","DrugName":"ACNE MEDICAT GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004010","GenericName":"BENZOYL PEROXIDE GEL 5%","NDC":"00536146725"},{"Id":389710,"FormularyType":"OHP","DrugName":"ORALYTE SOL STRAWBRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00536147217"},{"Id":389711,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 10% WASH","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"00536147442"},{"Id":389712,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"00536252525"},{"Id":389713,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536302906"},{"Id":389714,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536302923"},{"Id":389715,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536302934"},{"Id":389716,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536303006"},{"Id":389717,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536303023"},{"Id":389718,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536311201"},{"Id":389719,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536311237"},{"Id":389720,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536311301"},{"Id":389721,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536311337"},{"Id":389722,"FormularyType":"OHP","DrugName":"CIT CALC/D TAB 200-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"00536322301"},{"Id":389723,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536338601"},{"Id":389724,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536338701"},{"Id":389725,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG CINN","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"00536340401"},{"Id":389726,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"00536340501"},{"Id":389727,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00536360735"},{"Id":389728,"FormularyType":"OHP","DrugName":"CL PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"00536406301"},{"Id":389729,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"00536407810"},{"Id":389730,"FormularyType":"OHP","DrugName":"PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"00536408501"},{"Id":389731,"FormularyType":"OHP","DrugName":"FIBER-LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"00536430605"},{"Id":389732,"FormularyType":"OHP","DrugName":"FIBER-LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"00536430608"},{"Id":389733,"FormularyType":"OHP","DrugName":"FIBER-LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"00536430611"},{"Id":389734,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000305","GenericName":"PYRIDOXINE HCL TAB 25 MG","NDC":"00536440601"},{"Id":389735,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00536589453"},{"Id":389736,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"00536589488"},{"Id":389737,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00536589553"},{"Id":389738,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00536589571"},{"Id":389739,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"00536589588"},{"Id":389740,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00536589653"},{"Id":389741,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00536589671"},{"Id":389742,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"00536589688"},{"Id":389743,"FormularyType":"OHP","DrugName":"NIACIN TR TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000470","GenericName":"NIACIN TAB ER 1000 MG","NDC":"00536703801"},{"Id":389744,"FormularyType":"OHP","DrugName":"OYSCO 500+D TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00536781708"},{"Id":389745,"FormularyType":"OHP","DrugName":"OYSCO 500+D TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00536781710"},{"Id":389746,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"00548540000"},{"Id":389747,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"00548540025"},{"Id":389748,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"00548560100"},{"Id":389749,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"00548560200"},{"Id":389750,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"00548560300"},{"Id":389751,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"00548560400"},{"Id":389752,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"00548560500"},{"Id":389753,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"00548560600"},{"Id":389754,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"00548560700"},{"Id":389755,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 300/3ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101020102050","GenericName":"ENOXAPARIN SODIUM INJ 300 MG/3ML","NDC":"00548560800"},{"Id":389756,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2515003510E620","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML","NDC":"00548570100"},{"Id":389757,"FormularyType":"OHP","DrugName":"GLUCAGON INJ 1MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010002105","GenericName":"GLUCAGON FOR INJ 1 MG","NDC":"00548585000"},{"Id":389758,"FormularyType":"OHP","DrugName":"BAQSIMI ONE POW 3MG/DOSE","DosageForm":"POWD - Powder","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010002920","GenericName":"GLUCAGON NASAL POWDER 3 MG/DOSE","NDC":"00548835101"},{"Id":389759,"FormularyType":"OHP","DrugName":"BAQSIMI TWO POW 3MG/DOSE","DosageForm":"POWD - Powder","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010002920","GenericName":"GLUCAGON NASAL POWDER 3 MG/DOSE","NDC":"00548835202"},{"Id":389760,"FormularyType":"OHP","DrugName":"MEFLOQUINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000025100310","GenericName":"MEFLOQUINE HCL TAB 250 MG","NDC":"00555017178"},{"Id":389761,"FormularyType":"OHP","DrugName":"MEFLOQUINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000025100310","GenericName":"MEFLOQUINE HCL TAB 250 MG","NDC":"00555017188"},{"Id":389762,"FormularyType":"OHP","DrugName":"NORETHIN ACE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000030100305","GenericName":"NORETHINDRONE ACETATE TAB 5 MG","NDC":"00555021110"},{"Id":389763,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"00555030202"},{"Id":389764,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"00555030204"},{"Id":389765,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00555032302"},{"Id":389766,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00555032304"},{"Id":389767,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200115","GenericName":"HYDROXYZINE PAMOATE CAP 100 MG","NDC":"00555032402"},{"Id":389768,"FormularyType":"OHP","DrugName":"AMILOR/HCTZ TAB 5-50","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002100310","GenericName":"AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG","NDC":"00555048302"},{"Id":389769,"FormularyType":"OHP","DrugName":"AMILOR/HCTZ TAB 5-50","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002100310","GenericName":"AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG","NDC":"00555048305"},{"Id":389770,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00555048401"},{"Id":389771,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"00555048402"},{"Id":389772,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100345","GenericName":"LEUCOVORIN CALCIUM TAB 25 MG","NDC":"00555048527"},{"Id":389773,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"00555057202"},{"Id":389774,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"00555057235"},{"Id":389775,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100305","GenericName":"MEGESTROL ACETATE TAB 20 MG","NDC":"00555060602"},{"Id":389776,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100310","GenericName":"MEGESTROL ACETATE TAB 40 MG","NDC":"00555060702"},{"Id":389777,"FormularyType":"OHP","DrugName":"DANAZOL CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000105","GenericName":"DANAZOL CAP 50 MG","NDC":"00555063302"},{"Id":389778,"FormularyType":"OHP","DrugName":"DANAZOL CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000110","GenericName":"DANAZOL CAP 100 MG","NDC":"00555063402"},{"Id":389779,"FormularyType":"OHP","DrugName":"DANAZOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000115","GenericName":"DANAZOL CAP 200 MG","NDC":"00555063502"},{"Id":389780,"FormularyType":"OHP","DrugName":"DANAZOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000115","GenericName":"DANAZOL CAP 200 MG","NDC":"00555063509"},{"Id":389781,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"00555077502"},{"Id":389782,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"00555077602"},{"Id":389783,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"00555077702"},{"Id":389784,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200315","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 10 MG","NDC":"00555077902"},{"Id":389785,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200315","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 10 MG","NDC":"00555077904"},{"Id":389786,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200305","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 2.5 MG","NDC":"00555087202"},{"Id":389787,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200305","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 2.5 MG","NDC":"00555087204"},{"Id":389788,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200310","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 5 MG","NDC":"00555087302"},{"Id":389789,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200310","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 5 MG","NDC":"00555087304"},{"Id":389790,"FormularyType":"OHP","DrugName":"HYDROXYUREA CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700030000105","GenericName":"HYDROXYUREA CAP 500 MG","NDC":"00555088202"},{"Id":389791,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"00555088602"},{"Id":389792,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"00555088604"},{"Id":389793,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"00555088702"},{"Id":389794,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"00555088704"},{"Id":389795,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000303","GenericName":"ESTRADIOL TAB 0.5 MG","NDC":"00555089902"},{"Id":389796,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"00555095202"},{"Id":389797,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"00555095302"},{"Id":389798,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"00555097102"},{"Id":389799,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"00555097202"},{"Id":389800,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"00555097302"},{"Id":389801,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"00555097402"},{"Id":389802,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00555105456"},{"Id":389803,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00555105486"},{"Id":389804,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00555105556"},{"Id":389805,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00555105586"},{"Id":389806,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00555105660"},{"Id":389807,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00555105686"},{"Id":389808,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00555105756"},{"Id":389809,"FormularyType":"OHP","DrugName":"CLARAVIS CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00555105786"},{"Id":389810,"FormularyType":"OHP","DrugName":"NORTREL TAB 0.5/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500310","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","NDC":"00555900867"},{"Id":389811,"FormularyType":"OHP","DrugName":"NORTREL TAB 0.5/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500310","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","NDC":"00555900879"},{"Id":389812,"FormularyType":"OHP","DrugName":"NORTREL TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00555900942"},{"Id":389813,"FormularyType":"OHP","DrugName":"NORTREL TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00555900980"},{"Id":389814,"FormularyType":"OHP","DrugName":"NORTREL TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00555901058"},{"Id":389815,"FormularyType":"OHP","DrugName":"NORTREL TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00555901079"},{"Id":389816,"FormularyType":"OHP","DrugName":"NORTREL TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"00555901258"},{"Id":389817,"FormularyType":"OHP","DrugName":"NORTREL TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"00555901279"},{"Id":389818,"FormularyType":"OHP","DrugName":"LESSINA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"00555901467"},{"Id":389819,"FormularyType":"OHP","DrugName":"LESSINA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"00555901479"},{"Id":389820,"FormularyType":"OHP","DrugName":"SPRINTEC 28 TAB 28 DAY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"00555901658"},{"Id":389821,"FormularyType":"OHP","DrugName":"TRI-SPRINTEC TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"00555901858"},{"Id":389822,"FormularyType":"OHP","DrugName":"PORTIA-28 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00555902058"},{"Id":389823,"FormularyType":"OHP","DrugName":"PORTIA-28 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00555902079"},{"Id":389824,"FormularyType":"OHP","DrugName":"JUNEL 1/20 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"00555902542"},{"Id":389825,"FormularyType":"OHP","DrugName":"JUNEL FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"00555902658"},{"Id":389826,"FormularyType":"OHP","DrugName":"JUNEL 1.5/30 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"00555902742"},{"Id":389827,"FormularyType":"OHP","DrugName":"JUNEL FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"00555902858"},{"Id":389828,"FormularyType":"OHP","DrugName":"TRI-LEGEST TAB FE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992003300340","GenericName":"NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG","NDC":"00555903270"},{"Id":389829,"FormularyType":"OHP","DrugName":"BALZIVA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"00555903458"},{"Id":389830,"FormularyType":"OHP","DrugName":"BALZIVA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"00555903479"},{"Id":389831,"FormularyType":"OHP","DrugName":"APRI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00555904358"},{"Id":389832,"FormularyType":"OHP","DrugName":"APRI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"00555904379"},{"Id":389833,"FormularyType":"OHP","DrugName":"AVIANE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"00555904558"},{"Id":389834,"FormularyType":"OHP","DrugName":"AVIANE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"00555904579"},{"Id":389835,"FormularyType":"OHP","DrugName":"KARIVA TAB 28 DAY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"00555905058"},{"Id":389836,"FormularyType":"OHP","DrugName":"KARIVA TAB 28 DAY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"00555905079"},{"Id":389837,"FormularyType":"OHP","DrugName":"VELIVET PAK","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002030320","GenericName":"DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG","NDC":"00555905167"},{"Id":389838,"FormularyType":"OHP","DrugName":"VELIVET PAK","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002030320","GenericName":"DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG","NDC":"00555905179"},{"Id":389839,"FormularyType":"OHP","DrugName":"KELNOR TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00555906458"},{"Id":389840,"FormularyType":"OHP","DrugName":"KELNOR TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"00555906479"},{"Id":389841,"FormularyType":"OHP","DrugName":"ARANELLE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200330","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG","NDC":"00555906667"},{"Id":389842,"FormularyType":"OHP","DrugName":"ARANELLE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200330","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG","NDC":"00555906679"},{"Id":389843,"FormularyType":"OHP","DrugName":"JOLESSA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"00555912366"},{"Id":389844,"FormularyType":"OHP","DrugName":"PREP H CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"RECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89100010003705","GenericName":"HYDROCORTISONE PERIANAL CREAM 1%","NDC":"00573055211"},{"Id":389845,"FormularyType":"OHP","DrugName":"PREP H CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"RECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89100010003705","GenericName":"HYDROCORTISONE PERIANAL CREAM 1%","NDC":"00573283011"},{"Id":389846,"FormularyType":"OHP","DrugName":"CENTRUM CHW PRENATAL","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000524","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.18-25 MG***","NDC":"00573655296"},{"Id":389847,"FormularyType":"OHP","DrugName":"GLUTOSE 5 GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"00574006905"},{"Id":389848,"FormularyType":"OHP","DrugName":"GLUTOSE 15 GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"00574006915"},{"Id":389849,"FormularyType":"OHP","DrugName":"GLUTOSE 5 GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"00574006924"},{"Id":389850,"FormularyType":"OHP","DrugName":"GLUTOSE 15 GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"00574006930"},{"Id":389851,"FormularyType":"OHP","DrugName":"GLUTOSE 45 GEL","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"00574006945"},{"Id":389852,"FormularyType":"OHP","DrugName":"GLUTOSE 15 GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"00574007030"},{"Id":389853,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"00574010601"},{"Id":389854,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"00574010603"},{"Id":389855,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"00574010714"},{"Id":389856,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"00574010770"},{"Id":389857,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"00574010777"},{"Id":389858,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"00574014560"},{"Id":389859,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150340","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"00574022801"},{"Id":389860,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150330","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"00574022901"},{"Id":389861,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00574027500"},{"Id":389862,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00574027511"},{"Id":389863,"FormularyType":"OHP","DrugName":"AMILORIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500010100305","GenericName":"AMILORIDE HCL TAB 5 MG","NDC":"00574029201"},{"Id":389864,"FormularyType":"OHP","DrugName":"ORA-SWEET SF SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00574030216"},{"Id":389865,"FormularyType":"OHP","DrugName":"ORA-PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"00574030316"},{"Id":389866,"FormularyType":"OHP","DrugName":"ORA-SWEET SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00574030416"},{"Id":389867,"FormularyType":"OHP","DrugName":"ORA-BLEND SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"00574031116"},{"Id":389868,"FormularyType":"OHP","DrugName":"ORA-BLEND SF SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"00574031216"},{"Id":389869,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000319","GenericName":"FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)","NDC":"00574050801"},{"Id":389870,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000319","GenericName":"FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)","NDC":"00574050810"},{"Id":389871,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000319","GenericName":"FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)","NDC":"00574050811"},{"Id":389872,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"00574060801"},{"Id":389873,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"00574060810"},{"Id":389874,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"00574060811"},{"Id":389875,"FormularyType":"OHP","DrugName":"PODOFILOX SOL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750015002020","GenericName":"PODOFILOX SOLN 0.5%","NDC":"00574061105"},{"Id":389876,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000303","GenericName":"METHAZOLAMIDE TAB 25 MG","NDC":"00574079001"},{"Id":389877,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000305","GenericName":"METHAZOLAMIDE TAB 50 MG","NDC":"00574079101"},{"Id":389878,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00574082001"},{"Id":389879,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00574082010"},{"Id":389880,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00574082701"},{"Id":389881,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"00574082710"},{"Id":389882,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"00574140228"},{"Id":389883,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"00574140528"},{"Id":389884,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"00574141028"},{"Id":389885,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"00574141521"},{"Id":389886,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"00574142021"},{"Id":389887,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"00574142521"},{"Id":389888,"FormularyType":"OHP","DrugName":"NYSTOP POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"00574200802"},{"Id":389889,"FormularyType":"OHP","DrugName":"NYSTOP POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"00574200815"},{"Id":389890,"FormularyType":"OHP","DrugName":"NYSTOP POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"00574200830"},{"Id":389891,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"00574204205"},{"Id":389892,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"00574204213"},{"Id":389893,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"00574204230"},{"Id":389894,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"00574222520"},{"Id":389895,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"00574222545"},{"Id":389896,"FormularyType":"OHP","DrugName":"BRINZOLAMIDE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802320001820","GenericName":"BRINZOLAMIDE OPHTH SUSP 1%","NDC":"00574401210"},{"Id":389897,"FormularyType":"OHP","DrugName":"BRINZOLAMIDE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802320001820","GenericName":"BRINZOLAMIDE OPHTH SUSP 1%","NDC":"00574401215"},{"Id":389898,"FormularyType":"OHP","DrugName":"BACITRACIN OIN OP","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101005004205","GenericName":"BACITRACIN OPHTH OINT 500 UNIT/GM","NDC":"00574402235"},{"Id":389899,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"00574403105"},{"Id":389900,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"00574403110"},{"Id":389901,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"00574403125"},{"Id":389902,"FormularyType":"OHP","DrugName":"ASPIRIN SUP 300MG","DosageForm":"SUPP - Suppository","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010005218","GenericName":"ASPIRIN SUPPOS 300 MG","NDC":"00574703412"},{"Id":389903,"FormularyType":"OHP","DrugName":"BELLA/OPIUM SUP 16.2-60","DosageForm":"SUPP - Suppository","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49109902155220","GenericName":"BELLADONNA ALKALOIDS & OPIUM SUPPOS 16.2-60 MG","NDC":"00574704012"},{"Id":389904,"FormularyType":"OHP","DrugName":"BELLA/OPIUM SUP 16.2-30","DosageForm":"SUPP - Suppository","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49109902155210","GenericName":"BELLADONNA ALKALOIDS & OPIUM SUPPOS 16.2-30 MG","NDC":"00574704512"},{"Id":389905,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00574705012"},{"Id":389906,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00574705050"},{"Id":389907,"FormularyType":"OHP","DrugName":"MORPHINE SUL SUP 5MG","DosageForm":"SUPP - Suppository","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055105205","GenericName":"MORPHINE SULFATE SUPPOS 5 MG","NDC":"00574711012"},{"Id":389908,"FormularyType":"OHP","DrugName":"MORPHINE SUL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055105210","GenericName":"MORPHINE SULFATE SUPPOS 10 MG","NDC":"00574711212"},{"Id":389909,"FormularyType":"OHP","DrugName":"MORPHINE SUL SUP 20MG","DosageForm":"SUPP - Suppository","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055105215","GenericName":"MORPHINE SULFATE SUPPOS 20 MG","NDC":"00574711412"},{"Id":389910,"FormularyType":"OHP","DrugName":"MORPHINE SUL SUP 30MG","DosageForm":"SUPP - Suppository","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055105220","GenericName":"MORPHINE SULFATE SUPPOS 30 MG","NDC":"00574711612"},{"Id":389911,"FormularyType":"OHP","DrugName":"BUDESONIDE CAP 3MG DR","DosageForm":"CPEP - Capsule DR Part","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100012006720","GenericName":"BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","NDC":"00574985510"},{"Id":389912,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100305","GenericName":"VERAPAMIL HCL TAB 80 MG","NDC":"00591034301"},{"Id":389913,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100305","GenericName":"VERAPAMIL HCL TAB 80 MG","NDC":"00591034305"},{"Id":389914,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100305","GenericName":"VERAPAMIL HCL TAB 80 MG","NDC":"00591034310"},{"Id":389915,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100310","GenericName":"VERAPAMIL HCL TAB 120 MG","NDC":"00591034501"},{"Id":389916,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100310","GenericName":"VERAPAMIL HCL TAB 120 MG","NDC":"00591034505"},{"Id":389917,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100310","GenericName":"VERAPAMIL HCL TAB 120 MG","NDC":"00591034510"},{"Id":389918,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"00591034701"},{"Id":389919,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"00591034705"},{"Id":389920,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"00591034801"},{"Id":389921,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"00591034805"},{"Id":389922,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"00591034810"},{"Id":389923,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100303","GenericName":"VERAPAMIL HCL TAB 40 MG","NDC":"00591040401"},{"Id":389924,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"00591040501"},{"Id":389925,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"00591040505"},{"Id":389926,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"00591040601"},{"Id":389927,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"00591040610"},{"Id":389928,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"00591040701"},{"Id":389929,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"00591040710"},{"Id":389930,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"00591040801"},{"Id":389931,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"00591040810"},{"Id":389932,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"00591040901"},{"Id":389933,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"00591040905"},{"Id":389934,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"00591042401"},{"Id":389935,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"00591042405"},{"Id":389936,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"00591044401"},{"Id":389937,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"00591045301"},{"Id":389938,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"00591046001"},{"Id":389939,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"00591046005"},{"Id":389940,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"00591046010"},{"Id":389941,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"00591046101"},{"Id":389942,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"00591046105"},{"Id":389943,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"00591046110"},{"Id":389944,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00591079401"},{"Id":389945,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00591079410"},{"Id":389946,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00591079501"},{"Id":389947,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00591079510"},{"Id":389948,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"00591086001"},{"Id":389949,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"00591086005"},{"Id":389950,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"00591086101"},{"Id":389951,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"00591086105"},{"Id":389952,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"00591086201"},{"Id":389953,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"00591086205"},{"Id":389954,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"00591088501"},{"Id":389955,"FormularyType":"OHP","DrugName":"AZELAIC ACID GEL 15%","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060010004020","GenericName":"AZELAIC ACID GEL 15%","NDC":"00591213155"},{"Id":389956,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"00591219101"},{"Id":389957,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"00591219130"},{"Id":389958,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"00591224522"},{"Id":389959,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"00591240530"},{"Id":389960,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"00591240630"},{"Id":389961,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00591243315"},{"Id":389962,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00591243345"},{"Id":389963,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00591243415"},{"Id":389964,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00591243445"},{"Id":389965,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00591243515"},{"Id":389966,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00591243545"},{"Id":389967,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00591243615"},{"Id":389968,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00591243645"},{"Id":389969,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100310","GenericName":"TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00591247218"},{"Id":389970,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100310","GenericName":"TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00591247260"},{"Id":389971,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"00591247319"},{"Id":389972,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"00591247330"},{"Id":389973,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"00591247401"},{"Id":389974,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"00591247501"},{"Id":389975,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"00591252001"},{"Id":389976,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"00591252005"},{"Id":389977,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"00591253360"},{"Id":389978,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"00591257920"},{"Id":389979,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"00591268201"},{"Id":389980,"FormularyType":"OHP","DrugName":"ALBENDAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000002000320","GenericName":"ALBENDAZOLE TAB 200 MG","NDC":"00591271202"},{"Id":389981,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"00591272901"},{"Id":389982,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"00591274201"},{"Id":389983,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010007520","GenericName":"CLARITHROMYCIN TAB ER 24HR 500 MG","NDC":"00591280560"},{"Id":389984,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL PUMP 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004040","GenericName":"TESTOSTERONE TD GEL 12.5 MG/ACT (1%)","NDC":"00591292102"},{"Id":389985,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL PUMP 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004040","GenericName":"TESTOSTERONE TD GEL 12.5 MG/ACT (1%)","NDC":"00591292118"},{"Id":389986,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"00591292418"},{"Id":389987,"FormularyType":"OHP","DrugName":"LEVALBUTEROL AER 45/ACT","DosageForm":"AERO - Aerosol","Strength":"45","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201045503220","GenericName":"LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV)","NDC":"00591292754"},{"Id":389988,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"00591294430"},{"Id":389989,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"00591294460"},{"Id":389990,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"00591294487"},{"Id":389991,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"00591315901"},{"Id":389992,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(25MG)","DosageForm":"GEL - Gel","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004025","GenericName":"TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","NDC":"00591321617"},{"Id":389993,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(25MG)","DosageForm":"GEL - Gel","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004025","GenericName":"TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","NDC":"00591321630"},{"Id":389994,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00591321726"},{"Id":389995,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00591321730"},{"Id":389996,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00591352426"},{"Id":389997,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00591352430"},{"Id":389998,"FormularyType":"OHP","DrugName":"BUPROPION TAB 150MG SR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100002107430","GenericName":"BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG","NDC":"00591354360"},{"Id":389999,"FormularyType":"OHP","DrugName":"BUPROPION TAB 150MG SR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100002107430","GenericName":"BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG","NDC":"00591354376"},{"Id":390000,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"00591367001"},{"Id":390001,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"00591367005"},{"Id":390002,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"00591367101"},{"Id":390003,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"00591367105"},{"Id":390004,"FormularyType":"OHP","DrugName":"TRANEX ACID TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"HEMOSTATICS","DrugSubClass":"HEMOSTATICS - SYSTEMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"84100040000320","GenericName":"TRANEXAMIC ACID TAB 650 MG","NDC":"00591372030"},{"Id":390005,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"00591379519"},{"Id":390006,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"00591379530"},{"Id":390007,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"00591379619"},{"Id":390008,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"00591379630"},{"Id":390009,"FormularyType":"OHP","DrugName":"VIGABATRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085000320","GenericName":"VIGABATRIN TAB 500 MG","NDC":"00591385101"},{"Id":390010,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"00591387044"},{"Id":390011,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"00591387045"},{"Id":390012,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"00591387060"},{"Id":390013,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"00591387544"},{"Id":390014,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"00591387545"},{"Id":390015,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"00591387560"},{"Id":390016,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"00591398301"},{"Id":390017,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"00591398305"},{"Id":390018,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"00591398401"},{"Id":390019,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"00591398405"},{"Id":390020,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00591505201"},{"Id":390021,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00591505210"},{"Id":390022,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B705","GenericName":"PREDNISONE TAB THERAPY PACK 5 MG (21)","NDC":"00591505221"},{"Id":390023,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B710","GenericName":"PREDNISONE TAB THERAPY PACK 5 MG (48)","NDC":"00591505243"},{"Id":390024,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"00591530701"},{"Id":390025,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"00591530710"},{"Id":390026,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100315","GenericName":"PROMETHAZINE HCL TAB 50 MG","NDC":"00591531901"},{"Id":390027,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"00591532101"},{"Id":390028,"FormularyType":"OHP","DrugName":"PROBEN/COLCH TAB 500-0.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENT COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68990002100310","GenericName":"COLCHICINE W/ PROBENECID TAB 0.5-500 MG","NDC":"00591532501"},{"Id":390029,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100310","GenericName":"TRIHEXYPHENIDYL HCL TAB 2 MG","NDC":"00591533501"},{"Id":390030,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100310","GenericName":"TRIHEXYPHENIDYL HCL TAB 2 MG","NDC":"00591533510"},{"Id":390031,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100320","GenericName":"TRIHEXYPHENIDYL HCL TAB 5 MG","NDC":"00591533701"},{"Id":390032,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100320","GenericName":"TRIHEXYPHENIDYL HCL TAB 5 MG","NDC":"00591533710"},{"Id":390033,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"00591534701"},{"Id":390034,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"00591534710"},{"Id":390035,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00591544201"},{"Id":390036,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00591544205"},{"Id":390037,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00591544210"},{"Id":390038,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 10MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B720","GenericName":"PREDNISONE TAB THERAPY PACK 10 MG (21)","NDC":"00591544221"},{"Id":390039,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 10MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B725","GenericName":"PREDNISONE TAB THERAPY PACK 10 MG (48)","NDC":"00591544243"},{"Id":390040,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00591544301"},{"Id":390041,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00591544305"},{"Id":390042,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00591544310"},{"Id":390043,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00591554301"},{"Id":390044,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00591554310"},{"Id":390045,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00591554401"},{"Id":390046,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00591554405"},{"Id":390047,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000305","GenericName":"MINOXIDIL TAB 2.5 MG","NDC":"00591564201"},{"Id":390048,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000305","GenericName":"MINOXIDIL TAB 2.5 MG","NDC":"00591564205"},{"Id":390049,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000310","GenericName":"MINOXIDIL TAB 10 MG","NDC":"00591564301"},{"Id":390050,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000310","GenericName":"MINOXIDIL TAB 10 MG","NDC":"00591564305"},{"Id":390051,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"00591566001"},{"Id":390052,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"00591566005"},{"Id":390053,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"00591566101"},{"Id":390054,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"00591566105"},{"Id":390055,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"00591569401"},{"Id":390056,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"00591569460"},{"Id":390057,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"00591569550"},{"Id":390058,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100310","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","NDC":"00591578201"},{"Id":390059,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100320","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","NDC":"00591578301"},{"Id":390060,"FormularyType":"OHP","DrugName":"APTIVUS CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104585000120","GenericName":"TIPRANAVIR CAP 250 MG","NDC":"00597000302"},{"Id":390061,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00597005216"},{"Id":390062,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00597005228"},{"Id":390063,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00597005234"},{"Id":390064,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00597005238"},{"Id":390065,"FormularyType":"OHP","DrugName":"SPIRIVA RESP AER 2.5MCG","DosageForm":"AERS - Aerosol solution","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100080083420","GenericName":"TIOTROPIUM BROMIDE INHAL AEROSOL 2.5 MCG/ACT","NDC":"00597010051"},{"Id":390066,"FormularyType":"OHP","DrugName":"SPIRIVA RESP AER 2.5MCG","DosageForm":"AERS - Aerosol solution","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100080083420","GenericName":"TIOTROPIUM BROMIDE INHAL AEROSOL 2.5 MCG/ACT","NDC":"00597010061"},{"Id":390067,"FormularyType":"OHP","DrugName":"GILOTRIF TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360006100330","GenericName":"AFATINIB DIMALEATE TAB 30 MG (BASE EQUIVALENT)","NDC":"00597013730"},{"Id":390068,"FormularyType":"OHP","DrugName":"GILOTRIF TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360006100340","GenericName":"AFATINIB DIMALEATE TAB 40 MG (BASE EQUIVALENT)","NDC":"00597013830"},{"Id":390069,"FormularyType":"OHP","DrugName":"GILOTRIF TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360006100320","GenericName":"AFATINIB DIMALEATE TAB 20 MG (BASE EQUIVALENT)","NDC":"00597014130"},{"Id":390070,"FormularyType":"OHP","DrugName":"STIOLTO AER 2.5-2.5","DosageForm":"AERS - Aerosol solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902923420","GenericName":"TIOTROPIUM BR-OLODATEROL INHAL AERO SOLN 2.5-2.5 MCG/ACT","NDC":"00597015528"},{"Id":390071,"FormularyType":"OHP","DrugName":"STIOLTO AER 2.5-2.5","DosageForm":"AERS - Aerosol solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902923420","GenericName":"TIOTROPIUM BR-OLODATEROL INHAL AERO SOLN 2.5-2.5 MCG/ACT","NDC":"00597015561"},{"Id":390072,"FormularyType":"OHP","DrugName":"STIOLTO AER 2.5-2.5","DosageForm":"AERS - Aerosol solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902923420","GenericName":"TIOTROPIUM BR-OLODATEROL INHAL AERO SOLN 2.5-2.5 MCG/ACT","NDC":"00597015570"},{"Id":390073,"FormularyType":"OHP","DrugName":"SPIRIVA RESP AER 1.25MCG","DosageForm":"AERS - Aerosol solution","Strength":"1.25","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100080083410","GenericName":"TIOTROPIUM BROMIDE INHAL AEROSOL 1.25 MCG/ACT","NDC":"00597016061"},{"Id":390074,"FormularyType":"OHP","DrugName":"STRIVERDI AER 2.5MCG","DosageForm":"AERS - Aerosol solution","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201052203410","GenericName":"OLODATEROL HCL INHAL AEROSOL SOLN 2.5 MCG/ACT (BASE EQUIV)","NDC":"00597019261"},{"Id":390075,"FormularyType":"OHP","DrugName":"ADALIMU-ADBM KIT 20/0.4ML","DosageForm":"PSKT - Prefilled Syringe Kit","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001505F810","GenericName":"ADALIMUMAB-ADBM PREFILLED SYRINGE KIT 20 MG/0.4ML","NDC":"00597055580"},{"Id":390076,"FormularyType":"OHP","DrugName":"ADALIMU-ADBM KIT 10/0.2ML","DosageForm":"PSKT - Prefilled Syringe Kit","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001505F805","GenericName":"ADALIMUMAB-ADBM PREFILLED SYRINGE KIT 10 MG/0.2ML","NDC":"00597058589"},{"Id":390077,"FormularyType":"OHP","DrugName":"HERNEXEOS TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANTI-HER2 AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21170092000330","GenericName":"ZONGERTINIB TAB 60 MG","NDC":"00597925759"},{"Id":390078,"FormularyType":"OHP","DrugName":"HERNEXEOS TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANTI-HER2 AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21170092000330","GenericName":"ZONGERTINIB TAB 60 MG","NDC":"00597925786"},{"Id":390079,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"00603020922"},{"Id":390080,"FormularyType":"OHP","DrugName":"DICYCLOMINE SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010102050","GenericName":"DICYCLOMINE HCL ORAL SOLN 10 MG/5ML","NDC":"00603116158"},{"Id":390081,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00603154258"},{"Id":390082,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"00603154358"},{"Id":390083,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00603211521"},{"Id":390084,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00603211532"},{"Id":390085,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00603211621"},{"Id":390086,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00603211628"},{"Id":390087,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00603211632"},{"Id":390088,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00603240621"},{"Id":390089,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00603240628"},{"Id":390090,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00603240632"},{"Id":390091,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00603240721"},{"Id":390092,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00603240728"},{"Id":390093,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00603240732"},{"Id":390094,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"00603243321"},{"Id":390095,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"00603243332"},{"Id":390096,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"00603243421"},{"Id":390097,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"00603243432"},{"Id":390098,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"00603243521"},{"Id":390099,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"00603243532"},{"Id":390100,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"00603358121"},{"Id":390101,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"00603358128"},{"Id":390102,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"00603358221"},{"Id":390103,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"00603358228"},{"Id":390104,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"00603358321"},{"Id":390105,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"00603358328"},{"Id":390106,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210003000B705","GenericName":"METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","NDC":"00603459315"},{"Id":390107,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"00603459321"},{"Id":390108,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"00603516521"},{"Id":390109,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"00603516532"},{"Id":390110,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"00603516621"},{"Id":390111,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"00603516632"},{"Id":390112,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"00603516721"},{"Id":390113,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"00603516732"},{"Id":390114,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"00603516821"},{"Id":390115,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"00603516832"},{"Id":390116,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"00603533521"},{"Id":390117,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"00603533532"},{"Id":390118,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"00603533621"},{"Id":390119,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B705","GenericName":"PREDNISONE TAB THERAPY PACK 5 MG (21)","NDC":"00603533715"},{"Id":390120,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00603533721"},{"Id":390121,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B710","GenericName":"PREDNISONE TAB THERAPY PACK 5 MG (48)","NDC":"00603533731"},{"Id":390122,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"00603533732"},{"Id":390123,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 10MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B720","GenericName":"PREDNISONE TAB THERAPY PACK 10 MG (21)","NDC":"00603533815"},{"Id":390124,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00603533821"},{"Id":390125,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00603533828"},{"Id":390126,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 10MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B725","GenericName":"PREDNISONE TAB THERAPY PACK 10 MG (48)","NDC":"00603533831"},{"Id":390127,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00603533832"},{"Id":390128,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00603533921"},{"Id":390129,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00603533928"},{"Id":390130,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"00603533932"},{"Id":390131,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"00603548221"},{"Id":390132,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"00603548232"},{"Id":390133,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"00603548321"},{"Id":390134,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"00603548332"},{"Id":390135,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"00603548421"},{"Id":390136,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"00603548432"},{"Id":390137,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"00603548521"},{"Id":390138,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"00603548621"},{"Id":390139,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"00603548628"},{"Id":390140,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"00641037621"},{"Id":390141,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"00641037625"},{"Id":390142,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00641039112"},{"Id":390143,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00641039137"},{"Id":390144,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00641040012"},{"Id":390145,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00641040037"},{"Id":390146,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"00641041012"},{"Id":390147,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"00641041037"},{"Id":390148,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"00641049321"},{"Id":390149,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"00641049325"},{"Id":390150,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00641049717"},{"Id":390151,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"00641049725"},{"Id":390152,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641092821"},{"Id":390153,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641092825"},{"Id":390154,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641092921"},{"Id":390155,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641092925"},{"Id":390156,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641094831"},{"Id":390157,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641094835"},{"Id":390158,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641094931"},{"Id":390159,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641094935"},{"Id":390160,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641095521"},{"Id":390161,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641095525"},{"Id":390162,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641095621"},{"Id":390163,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641095625"},{"Id":390164,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641149531"},{"Id":390165,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641149535"},{"Id":390166,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641149631"},{"Id":390167,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"00641149635"},{"Id":390168,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00641234139"},{"Id":390169,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00641234141"},{"Id":390170,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00641245030"},{"Id":390171,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00641245055"},{"Id":390172,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00641246030"},{"Id":390173,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00641246055"},{"Id":390174,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"00641255510"},{"Id":390175,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641600701"},{"Id":390176,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641600710"},{"Id":390177,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641600801"},{"Id":390178,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641600810"},{"Id":390179,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641604401"},{"Id":390180,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641604425"},{"Id":390181,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641604501"},{"Id":390182,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641604525"},{"Id":390183,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641604601"},{"Id":390184,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641604610"},{"Id":390185,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641604701"},{"Id":390186,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641604710"},{"Id":390187,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641604801"},{"Id":390188,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641604825"},{"Id":390189,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641604901"},{"Id":390190,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641604925"},{"Id":390191,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641605001"},{"Id":390192,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641605010"},{"Id":390193,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641605101"},{"Id":390194,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002010","GenericName":"LORAZEPAM INJ 4 MG/ML","NDC":"00641605110"},{"Id":390195,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"00641605901"},{"Id":390196,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"00641605910"},{"Id":390197,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50MG/10","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00641606001"},{"Id":390198,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50MG/10","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00641606010"},{"Id":390199,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102005","GenericName":"MIDAZOLAM HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00641606125"},{"Id":390200,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102010","GenericName":"MIDAZOLAM HCL INJ 10 MG/2ML (BASE EQUIVALENT)","NDC":"00641606325"},{"Id":390201,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"00641611601"},{"Id":390202,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"00641611610"},{"Id":390203,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"00641611701"},{"Id":390204,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"00641611710"},{"Id":390205,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"00641611801"},{"Id":390206,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"00641613201"},{"Id":390207,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"00641613225"},{"Id":390208,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"00641613601"},{"Id":390209,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"00641613625"},{"Id":390210,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"00641613701"},{"Id":390211,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"00641613710"},{"Id":390212,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"00641613801"},{"Id":390213,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"00641613825"},{"Id":390214,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"00641613910"},{"Id":390215,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00641614701"},{"Id":390216,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00641614710"},{"Id":390217,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00641614725"},{"Id":390218,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00641615101"},{"Id":390219,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00641615125"},{"Id":390220,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"00641616601"},{"Id":390221,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"00641616610"},{"Id":390222,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"00641616701"},{"Id":390223,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"00641616710"},{"Id":390224,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00641616901"},{"Id":390225,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00641616910"},{"Id":390226,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"00641617501"},{"Id":390227,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"00641617510"},{"Id":390228,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102030","GenericName":"OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML)","NDC":"00641617801"},{"Id":390229,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00641619001"},{"Id":390230,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00641619010"},{"Id":390231,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102006","GenericName":"MORPHINE SULFATE IV SOLN 2 MG/ML","NDC":"00641619101"},{"Id":390232,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102006","GenericName":"MORPHINE SULFATE IV SOLN 2 MG/ML","NDC":"00641619110"},{"Id":390233,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 0.4MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E510","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 0.4 MG/ML","NDC":"00641619301"},{"Id":390234,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 0.4MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E510","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 0.4 MG/ML","NDC":"00641619310"},{"Id":390235,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202026","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/ML","NDC":"00641619901"},{"Id":390236,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202026","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/ML","NDC":"00641619910"},{"Id":390237,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"00641620401"},{"Id":390238,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"00641620410"},{"Id":390239,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"00641620501"},{"Id":390240,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"00641620510"},{"Id":390241,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 0.5/0.5","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00641620601"},{"Id":390242,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 0.5/0.5","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102005","GenericName":"HYDROMORPHONE HCL INJ 1 MG/ML","NDC":"00641620610"},{"Id":390243,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641620701"},{"Id":390244,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"00641620725"},{"Id":390245,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641620801"},{"Id":390246,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"00641620825"},{"Id":390247,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"00641621001"},{"Id":390248,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"00641621010"},{"Id":390249,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00641621101"},{"Id":390250,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"00641621110"},{"Id":390251,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102011","GenericName":"MIDAZOLAM HCL INJ PF 10 MG/2ML (BASE EQUIVALENT)","NDC":"00641621901"},{"Id":390252,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102011","GenericName":"MIDAZOLAM HCL INJ PF 10 MG/2ML (BASE EQUIVALENT)","NDC":"00641621910"},{"Id":390253,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 40/20ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102010","GenericName":"HYDROMORPHONE HCL INJ 2 MG/ML","NDC":"00641625401"},{"Id":390254,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 0.2MG/ML","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102002","GenericName":"HYDROMORPHONE HCL INJ 0.2 MG/ML","NDC":"00641625901"},{"Id":390255,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 0.2MG/ML","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102002","GenericName":"HYDROMORPHONE HCL INJ 0.2 MG/ML","NDC":"00641625910"},{"Id":390256,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"O","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"00641626701"},{"Id":390257,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"O","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"00641626710"},{"Id":390258,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"00641628201"},{"Id":390259,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"00641628225"},{"Id":390260,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641628401"},{"Id":390261,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641628410"},{"Id":390262,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641628501"},{"Id":390263,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"00641628510"},{"Id":390264,"FormularyType":"OHP","DrugName":"STUART ONE CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516015000130","GenericName":"*PRENATAL MV & MIN W/FE CARBONYL-FA-DHA CAP 27-0.8-200 MG**","NDC":"00642403030"},{"Id":390265,"FormularyType":"OHP","DrugName":"BENZNIDAZOLE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000003000320","GenericName":"BENZNIDAZOLE TAB 12.5 MG","NDC":"00642746312"},{"Id":390266,"FormularyType":"OHP","DrugName":"BENZNIDAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000003000340","GenericName":"BENZNIDAZOLE TAB 100 MG","NDC":"00642746410"},{"Id":390267,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 500/50ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00703001801"},{"Id":390268,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00703011001"},{"Id":390269,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00703011003"},{"Id":390270,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"00703011303"},{"Id":390271,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"00703024101"},{"Id":390272,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"00703024301"},{"Id":390273,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"00703024501"},{"Id":390274,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002050","GenericName":"TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML)","NDC":"00703066601"},{"Id":390275,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002060","GenericName":"TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML)","NDC":"00703067601"},{"Id":390276,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002070","GenericName":"TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML)","NDC":"00703068601"},{"Id":390277,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002080","GenericName":"TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML)","NDC":"00703069601"},{"Id":390278,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 50MG/2ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102063","GenericName":"METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML)","NDC":"00703367101"},{"Id":390279,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 250/10ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102069","GenericName":"METHOTREXATE SODIUM INJ PF 250 MG/10ML (25 MG/ML)","NDC":"00703367501"},{"Id":390280,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM/40ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102075","GenericName":"METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML)","NDC":"00703367801"},{"Id":390281,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00703450201"},{"Id":390282,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00703450204"},{"Id":390283,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00703450291"},{"Id":390284,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"00703450293"},{"Id":390285,"FormularyType":"OHP","DrugName":"PROCHLORPER SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055005215","GenericName":"PROCHLORPERAZINE SUPPOS 25 MG","NDC":"00713013506"},{"Id":390286,"FormularyType":"OHP","DrugName":"PROCHLORPER SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055005215","GenericName":"PROCHLORPERAZINE SUPPOS 25 MG","NDC":"00713013512"},{"Id":390287,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"00713022515"},{"Id":390288,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"00713022531"},{"Id":390289,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"00713022580"},{"Id":390290,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"00713022615"},{"Id":390291,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"00713022680"},{"Id":390292,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"00713022815"},{"Id":390293,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"00713022831"},{"Id":390294,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"00713022880"},{"Id":390295,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"00713022915"},{"Id":390296,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"00713022980"},{"Id":390297,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00713026831"},{"Id":390298,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"00713028031"},{"Id":390299,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025002020","GenericName":"CALCIPOTRIENE SOLN 0.005% (50 MCG/ML)","NDC":"00713031853"},{"Id":390300,"FormularyType":"OHP","DrugName":"BETAMETH VAL CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020103710","GenericName":"BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","NDC":"00713032615"},{"Id":390301,"FormularyType":"OHP","DrugName":"BETAMETH VAL CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020103710","GenericName":"BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","NDC":"00713032637"},{"Id":390302,"FormularyType":"OHP","DrugName":"BETAMETH VAL OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020104205","GenericName":"BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT)","NDC":"00713032715"},{"Id":390303,"FormularyType":"OHP","DrugName":"BETAMETH VAL OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020104205","GenericName":"BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT)","NDC":"00713032737"},{"Id":390304,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"00713057571"},{"Id":390305,"FormularyType":"OHP","DrugName":"KETOCONAZOLE SHA 2%","DosageForm":"SHAM - Shampoo","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004510","GenericName":"KETOCONAZOLE SHAMPOO 2%","NDC":"00713059204"},{"Id":390306,"FormularyType":"OHP","DrugName":"MICONAZOLE KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"00713059377"},{"Id":390307,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"00713062231"},{"Id":390308,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"00713063115"},{"Id":390309,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"00713063131"},{"Id":390310,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"00713063160"},{"Id":390311,"FormularyType":"OHP","DrugName":"FLUTICASONE OIN 0.005%","DosageForm":"OINT - Ointment","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068104210","GenericName":"FLUTICASONE PROPIONATE OINT 0.005%","NDC":"00713063215"},{"Id":390312,"FormularyType":"OHP","DrugName":"FLUTICASONE OIN 0.005%","DosageForm":"OINT - Ointment","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068104210","GenericName":"FLUTICASONE PROPIONATE OINT 0.005%","NDC":"00713063231"},{"Id":390313,"FormularyType":"OHP","DrugName":"FLUTICASONE OIN 0.005%","DosageForm":"OINT - Ointment","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068104210","GenericName":"FLUTICASONE PROPIONATE OINT 0.005%","NDC":"00713063260"},{"Id":390314,"FormularyType":"OHP","DrugName":"METRONIDAZOL CRE 0.75%","DosageForm":"CREA - Cream","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040003710","GenericName":"METRONIDAZOLE CREAM 0.75%","NDC":"00713063337"},{"Id":390315,"FormularyType":"OHP","DrugName":"MOMETASONE CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082103710","GenericName":"MOMETASONE FUROATE CREAM 0.1%","NDC":"00713063415"},{"Id":390316,"FormularyType":"OHP","DrugName":"MOMETASONE CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082103710","GenericName":"MOMETASONE FUROATE CREAM 0.1%","NDC":"00713063437"},{"Id":390317,"FormularyType":"OHP","DrugName":"MOMETASONE OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082104210","GenericName":"MOMETASONE FUROATE OINT 0.1%","NDC":"00713063515"},{"Id":390318,"FormularyType":"OHP","DrugName":"MOMETASONE OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082104210","GenericName":"MOMETASONE FUROATE OINT 0.1%","NDC":"00713063537"},{"Id":390319,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040004010","GenericName":"METRONIDAZOLE GEL 0.75%","NDC":"00713063737"},{"Id":390320,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"00713063815"},{"Id":390321,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"00713063818"},{"Id":390322,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"00713063831"},{"Id":390323,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00713065615"},{"Id":390324,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00713065631"},{"Id":390325,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00713065637"},{"Id":390326,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"00713065660"},{"Id":390327,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"00713065915"},{"Id":390328,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"00713065937"},{"Id":390329,"FormularyType":"OHP","DrugName":"TRIAMCINOLON LOT 0.1%","DosageForm":"LOTN - Lotion","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104110","GenericName":"TRIAMCINOLONE ACETONIDE LOTION 0.1%","NDC":"00713067653"},{"Id":390330,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"00713067815"},{"Id":390331,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"00713067831"},{"Id":390332,"FormularyType":"OHP","DrugName":"GENTAMICIN OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050104205","GenericName":"GENTAMICIN SULFATE OINT 0.1%","NDC":"00713068215"},{"Id":390333,"FormularyType":"OHP","DrugName":"GENTAMICIN OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050104205","GenericName":"GENTAMICIN SULFATE OINT 0.1%","NDC":"00713068231"},{"Id":390334,"FormularyType":"OHP","DrugName":"GENTAMICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050103705","GenericName":"GENTAMICIN SULFATE CREAM 0.1%","NDC":"00713068315"},{"Id":390335,"FormularyType":"OHP","DrugName":"GENTAMICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050103705","GenericName":"GENTAMICIN SULFATE CREAM 0.1%","NDC":"00713068331"},{"Id":390336,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"00713068615"},{"Id":390337,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"00713068631"},{"Id":390338,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00713079175"},{"Id":390339,"FormularyType":"OHP","DrugName":"BETAMETH DIP LOT 0.05%","DosageForm":"LOTN - Lotion","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004105","GenericName":"BETAMETHASONE DIPROPIONATE LOTION 0.05%","NDC":"00713080753"},{"Id":390340,"FormularyType":"OHP","DrugName":"HC/ACET ACID SOL 1-2%OTIC","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87300020102000","GenericName":"HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%","NDC":"00713084909"},{"Id":390341,"FormularyType":"OHP","DrugName":"GRISEOFULVIN SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000030101805","GenericName":"GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML","NDC":"00713085004"},{"Id":390342,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00722711601"},{"Id":390343,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00722711602"},{"Id":390344,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"00722711603"},{"Id":390345,"FormularyType":"OHP","DrugName":"NIACIN CAP 500MG TR","DosageForm":"CPCR - Capsule ER","Strength":"500","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000220","GenericName":"NIACIN CAP ER 500 MG","NDC":"00761004920"},{"Id":390346,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"00761005820"},{"Id":390347,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"00761009840"},{"Id":390348,"FormularyType":"OHP","DrugName":"PRENATAL VIT TAB 27-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"00761010418"},{"Id":390349,"FormularyType":"OHP","DrugName":"FISH OIL CON CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"00761010832"},{"Id":390350,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00761012945"},{"Id":390351,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"00761015540"},{"Id":390352,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"00761015724"},{"Id":390353,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"00761017140"},{"Id":390354,"FormularyType":"OHP","DrugName":"CALCIUM CITR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000310","GenericName":"CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA)","NDC":"00761019520"},{"Id":390355,"FormularyType":"OHP","DrugName":"SENNA LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00761022020"},{"Id":390356,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 CR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"00761022120"},{"Id":390357,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"00761023920"},{"Id":390358,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"00761030520"},{"Id":390359,"FormularyType":"OHP","DrugName":"ANTI-HIST TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00761031620"},{"Id":390360,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00761035250"},{"Id":390361,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00761035920"},{"Id":390362,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"00761037220"},{"Id":390363,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"00761043620"},{"Id":390364,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"00761044020"},{"Id":390365,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"00761055520"},{"Id":390366,"FormularyType":"OHP","DrugName":"NIACIN CAP 250MG TR","DosageForm":"CPCR - Capsule ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000210","GenericName":"NIACIN CAP ER 250 MG","NDC":"00761067720"},{"Id":390367,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"00761081212"},{"Id":390368,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"00761081232"},{"Id":390369,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"00761081264"},{"Id":390370,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 550MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000311","GenericName":"POTASSIUM GLUCONATE TAB 2.5 MEQ","NDC":"00761084720"},{"Id":390371,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"00761087840"},{"Id":390372,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00761094020"},{"Id":390373,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"00781120392"},{"Id":390374,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"00781155601"},{"Id":390375,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"00781155610"},{"Id":390376,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"00781163501"},{"Id":390377,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"00781163510"},{"Id":390378,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00781168401"},{"Id":390379,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"00781169501"},{"Id":390380,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"00781169510"},{"Id":390381,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"00781183101"},{"Id":390382,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"00781183120"},{"Id":390383,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"00781185201"},{"Id":390384,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"00781185220"},{"Id":390385,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 250-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200310","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 250-125 MG","NDC":"00781187431"},{"Id":390386,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"00781189101"},{"Id":390387,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"00781189201"},{"Id":390388,"FormularyType":"OHP","DrugName":"AMOX-POT CLA TAB ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002207420","GenericName":"AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG","NDC":"00781194339"},{"Id":390389,"FormularyType":"OHP","DrugName":"AMOX-POT CLA TAB ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002207420","GenericName":"AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG","NDC":"00781194382"},{"Id":390390,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000310","GenericName":"CLARITHROMYCIN TAB 250 MG","NDC":"00781196160"},{"Id":390391,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"00781196260"},{"Id":390392,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"00781202001"},{"Id":390393,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"00781202005"},{"Id":390394,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"00781202076"},{"Id":390395,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00781206701"},{"Id":390396,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00781206705"},{"Id":390397,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00781206789"},{"Id":390398,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"00781207401"},{"Id":390399,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"00781207410"},{"Id":390400,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"00781207601"},{"Id":390401,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"00781210201"},{"Id":390402,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"00781210301"},{"Id":390403,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"00781210401"},{"Id":390404,"FormularyType":"OHP","DrugName":"AMPICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020200110","GenericName":"AMPICILLIN CAP 500 MG","NDC":"00781214501"},{"Id":390405,"FormularyType":"OHP","DrugName":"AMPICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020200110","GenericName":"AMPICILLIN CAP 500 MG","NDC":"00781214505"},{"Id":390406,"FormularyType":"OHP","DrugName":"PIRFENIDONE CAP 267MG","DosageForm":"CAPS - Capsule","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000120","GenericName":"PIRFENIDONE CAP 267 MG","NDC":"00781215832"},{"Id":390407,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"00781217660"},{"Id":390408,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"00781223401"},{"Id":390409,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"00781223410"},{"Id":390410,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"00781223431"},{"Id":390411,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 25MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006830","GenericName":"TOPIRAMATE SPRINKLE CAP 25 MG","NDC":"00781227660"},{"Id":390412,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"00781229901"},{"Id":390413,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"00781232106"},{"Id":390414,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"00781232151"},{"Id":390415,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"00781232246"},{"Id":390416,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"00781232268"},{"Id":390417,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"00781232901"},{"Id":390418,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"00781233501"},{"Id":390419,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"00781236801"},{"Id":390420,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"00781247601"},{"Id":390421,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"00781247701"},{"Id":390422,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"00781247801"},{"Id":390423,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"00781247901"},{"Id":390424,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"00781248001"},{"Id":390425,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"00781248101"},{"Id":390426,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"00781261301"},{"Id":390427,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"00781261305"},{"Id":390428,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"00781261376"},{"Id":390429,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"00781285901"},{"Id":390430,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"00781285910"},{"Id":390431,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"00781285931"},{"Id":390432,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"00781286801"},{"Id":390433,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"00781286810"},{"Id":390434,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"00781286831"},{"Id":390435,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"00781286892"},{"Id":390436,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00781300094"},{"Id":390437,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00781300095"},{"Id":390438,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"00781300096"},{"Id":390439,"FormularyType":"OHP","DrugName":"OMNITROPE INJ 5/1.5ML","DosageForm":"SOCT - Soln Cartridge","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E210","GenericName":"SOMATROPIN SOLUTION CARTRIDGE 5 MG/1.5ML","NDC":"00781300107"},{"Id":390440,"FormularyType":"OHP","DrugName":"OMNITROPE INJ 10/1.5ML","DosageForm":"SOCT - Soln Cartridge","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000E213","GenericName":"SOMATROPIN SOLUTION CARTRIDGE 10 MG/1.5ML","NDC":"00781300407"},{"Id":390441,"FormularyType":"OHP","DrugName":"REGONOL INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050102010","GenericName":"PYRIDOSTIGMINE BROMIDE IV SOLN 10 MG/2ML (5 MG/ML)","NDC":"00781304072"},{"Id":390442,"FormularyType":"OHP","DrugName":"REGONOL INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050102010","GenericName":"PYRIDOSTIGMINE BROMIDE IV SOLN 10 MG/2ML (5 MG/ML)","NDC":"00781304095"},{"Id":390443,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00781309894"},{"Id":390444,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00781309895"},{"Id":390445,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"00781309896"},{"Id":390446,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"00781311090"},{"Id":390447,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"00781311095"},{"Id":390448,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"00781311390"},{"Id":390449,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"00781311395"},{"Id":390450,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"00781311491"},{"Id":390451,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"00781311495"},{"Id":390452,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 40.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"00781318094"},{"Id":390453,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00781320685"},{"Id":390454,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"00781320695"},{"Id":390455,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00781320785"},{"Id":390456,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"00781320795"},{"Id":390457,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00781320885"},{"Id":390458,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"00781320895"},{"Id":390459,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00781320990"},{"Id":390460,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"00781320995"},{"Id":390461,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102125","GenericName":"CEFTRIAXONE SODIUM FOR INJ 10 GM","NDC":"00781321046"},{"Id":390462,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"00781322280"},{"Id":390463,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"00781322295"},{"Id":390464,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"00781322391"},{"Id":390465,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"00781322395"},{"Id":390466,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"00781323801"},{"Id":390467,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"00781323863"},{"Id":390468,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"00781324602"},{"Id":390469,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"00781324664"},{"Id":390470,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"00781325603"},{"Id":390471,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"00781325666"},{"Id":390472,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"00781326204"},{"Id":390473,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"00781326268"},{"Id":390474,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"00781326805"},{"Id":390475,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"00781326869"},{"Id":390476,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 300/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312020","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 300 MG/50ML","NDC":"00781328809"},{"Id":390477,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 300/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312020","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 300 MG/50ML","NDC":"00781328891"},{"Id":390478,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00781328909"},{"Id":390479,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"00781328991"},{"Id":390480,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00781329009"},{"Id":390481,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"00781329091"},{"Id":390482,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"00781329804"},{"Id":390483,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"00781329868"},{"Id":390484,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"00781329905"},{"Id":390485,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"00781329969"},{"Id":390486,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302110","GenericName":"AMPICILLIN SODIUM FOR INJ 250 MG","NDC":"00781340278"},{"Id":390487,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302110","GenericName":"AMPICILLIN SODIUM FOR INJ 250 MG","NDC":"00781340295"},{"Id":390488,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"00781340485"},{"Id":390489,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"00781340495"},{"Id":390490,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"00781340778"},{"Id":390491,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"00781340795"},{"Id":390492,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"00781340880"},{"Id":390493,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"00781340895"},{"Id":390494,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"00781340946"},{"Id":390495,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"00781340995"},{"Id":390496,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302122","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 1 GM","NDC":"00781341215"},{"Id":390497,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302122","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 1 GM","NDC":"00781341292"},{"Id":390498,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302127","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 2 GM","NDC":"00781341315"},{"Id":390499,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302127","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 2 GM","NDC":"00781341392"},{"Id":390500,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002050","GenericName":"TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML)","NDC":"00781342080"},{"Id":390501,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002060","GenericName":"TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML)","NDC":"00781342580"},{"Id":390502,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002070","GenericName":"TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML)","NDC":"00781342780"},{"Id":390503,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002080","GenericName":"TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML)","NDC":"00781343080"},{"Id":390504,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"00781343346"},{"Id":390505,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"00781343395"},{"Id":390506,"FormularyType":"OHP","DrugName":"COSYNTROPIN INJ 0.25MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC DRUGS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94200037002105","GenericName":"COSYNTROPIN FOR INJ 0.25 MG","NDC":"00781344071"},{"Id":390507,"FormularyType":"OHP","DrugName":"COSYNTROPIN INJ 0.25MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC DRUGS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94200037002105","GenericName":"COSYNTROPIN FOR INJ 0.25 MG","NDC":"00781344095"},{"Id":390508,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"00781344312"},{"Id":390509,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"00781344395"},{"Id":390510,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"00781345170"},{"Id":390511,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"00781345195"},{"Id":390512,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"00781345246"},{"Id":390513,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"00781345295"},{"Id":390514,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"00781345412"},{"Id":390515,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"00781345495"},{"Id":390516,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"00781346512"},{"Id":390517,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"00781346595"},{"Id":390518,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"00781347612"},{"Id":390519,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"00781347695"},{"Id":390520,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00781353810"},{"Id":390521,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00781353825"},{"Id":390522,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/10","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00781354010"},{"Id":390523,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/10","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00781354025"},{"Id":390524,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 30000/30","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00781354310"},{"Id":390525,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 30000/30","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"00781354325"},{"Id":390526,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00781354510"},{"Id":390527,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00781354525"},{"Id":390528,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 50000/10","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00781355010"},{"Id":390529,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 50000/10","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"00781355025"},{"Id":390530,"FormularyType":"OHP","DrugName":"LEUPROLIDE INJ 1MG/0.2","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"00781400332"},{"Id":390531,"FormularyType":"OHP","DrugName":"APREPITANT PAK 125 & 80","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020006320","GenericName":"APREPITANT CAPSULE THERAPY PACK 80 & 125 MG","NDC":"00781406336"},{"Id":390532,"FormularyType":"OHP","DrugName":"DROS/ETH EST TAB LEVOMEFO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200320","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG","NDC":"00781407515"},{"Id":390533,"FormularyType":"OHP","DrugName":"DROS/ETH EST TAB LEVOMEFO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200320","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG","NDC":"00781407552"},{"Id":390534,"FormularyType":"OHP","DrugName":"DROS/ETH EST TAB LEVOMEFO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200330","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG","NDC":"00781410315"},{"Id":390535,"FormularyType":"OHP","DrugName":"DROS/ETH EST TAB LEVOMEFO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200330","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG","NDC":"00781410352"},{"Id":390536,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"00781506101"},{"Id":390537,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"00781506120"},{"Id":390538,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"00781507031"},{"Id":390539,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"00781507092"},{"Id":390540,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"00781517501"},{"Id":390541,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"00781517505"},{"Id":390542,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"00781522101"},{"Id":390543,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"00781522201"},{"Id":390544,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"00781522301"},{"Id":390545,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"00781522401"},{"Id":390546,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"00781531701"},{"Id":390547,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"00781531710"},{"Id":390548,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"00781531801"},{"Id":390549,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"00781531810"},{"Id":390550,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"00781532501"},{"Id":390551,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"00781532531"},{"Id":390552,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100320","GenericName":"CEFPODOXIME PROXETIL TAB 100 MG","NDC":"00781543820"},{"Id":390553,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100330","GenericName":"CEFPODOXIME PROXETIL TAB 200 MG","NDC":"00781543901"},{"Id":390554,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100330","GenericName":"CEFPODOXIME PROXETIL TAB 200 MG","NDC":"00781543920"},{"Id":390555,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"00781557801"},{"Id":390556,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"00781566731"},{"Id":390557,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"00781566831"},{"Id":390558,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"00781569005"},{"Id":390559,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"00781569031"},{"Id":390560,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"00781569092"},{"Id":390561,"FormularyType":"OHP","DrugName":"BRINZOLAMIDE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802320001820","GenericName":"BRINZOLAMIDE OPHTH SUSP 1%","NDC":"00781601470"},{"Id":390562,"FormularyType":"OHP","DrugName":"BRINZOLAMIDE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802320001820","GenericName":"BRINZOLAMIDE OPHTH SUSP 1%","NDC":"00781601485"},{"Id":390563,"FormularyType":"OHP","DrugName":"CLARITHROMYC SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"N","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010001910","GenericName":"CLARITHROMYCIN FOR SUSP 125 MG/5ML","NDC":"00781602246"},{"Id":390564,"FormularyType":"OHP","DrugName":"CLARITHROMYC SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"N","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010001910","GenericName":"CLARITHROMYCIN FOR SUSP 125 MG/5ML","NDC":"00781602252"},{"Id":390565,"FormularyType":"OHP","DrugName":"CLARITHROMYC SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"N","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010001920","GenericName":"CLARITHROMYCIN FOR SUSP 250 MG/5ML","NDC":"00781602346"},{"Id":390566,"FormularyType":"OHP","DrugName":"CLARITHROMYC SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"N","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010001920","GenericName":"CLARITHROMYCIN FOR SUSP 250 MG/5ML","NDC":"00781602352"},{"Id":390567,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"00781603946"},{"Id":390568,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"00781603955"},{"Id":390569,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"00781603958"},{"Id":390570,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00781604146"},{"Id":390571,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00781604155"},{"Id":390572,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"00781604158"},{"Id":390573,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00781610246"},{"Id":390574,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00781610252"},{"Id":390575,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"00781610257"},{"Id":390576,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00781610446"},{"Id":390577,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00781610452"},{"Id":390578,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"00781610457"},{"Id":390579,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"00781613594"},{"Id":390580,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"00781613595"},{"Id":390581,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 20MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"20000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102135","GenericName":"PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","NDC":"00781613694"},{"Id":390582,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00781613948"},{"Id":390583,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00781613954"},{"Id":390584,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"00781613957"},{"Id":390585,"FormularyType":"OHP","DrugName":"PEN G SODIUM INJ 5000000","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010202105","GenericName":"PENICILLIN G SODIUM FOR INJ 5000000 UNIT","NDC":"00781615394"},{"Id":390586,"FormularyType":"OHP","DrugName":"PEN G SODIUM INJ 5000000","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"N","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010202105","GenericName":"PENICILLIN G SODIUM FOR INJ 5000000 UNIT","NDC":"00781615395"},{"Id":390587,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00781615646"},{"Id":390588,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00781615652"},{"Id":390589,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"00781615657"},{"Id":390590,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00781615746"},{"Id":390591,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00781615752"},{"Id":390592,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"00781615757"},{"Id":390593,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"00781618667"},{"Id":390594,"FormularyType":"OHP","DrugName":"AMLACTIN LOT DAILY","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"00781709879"},{"Id":390595,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008840","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR","NDC":"00781710454"},{"Id":390596,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008840","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR","NDC":"00781710458"},{"Id":390597,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008810","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR","NDC":"00781711954"},{"Id":390598,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008810","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR","NDC":"00781711958"},{"Id":390599,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTWK - Patch Weekly","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008815","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR)","NDC":"00781712254"},{"Id":390600,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTWK - Patch Weekly","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008815","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR)","NDC":"00781712258"},{"Id":390601,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"00781712958"},{"Id":390602,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"00781712983"},{"Id":390603,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008820","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR","NDC":"00781713354"},{"Id":390604,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008820","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR","NDC":"00781713358"},{"Id":390605,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.06MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.06","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008824","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR","NDC":"00781713454"},{"Id":390606,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.06MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.06","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008824","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR","NDC":"00781713458"},{"Id":390607,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"00781713593"},{"Id":390608,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008830","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR","NDC":"00781713654"},{"Id":390609,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTWK - Patch Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008830","GenericName":"ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR","NDC":"00781713658"},{"Id":390610,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"00781713858"},{"Id":390611,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"00781713883"},{"Id":390612,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"00781714458"},{"Id":390613,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"00781714483"},{"Id":390614,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"00781715683"},{"Id":390615,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00781715729"},{"Id":390616,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00781715764"},{"Id":390617,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"00781715786"},{"Id":390618,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"00781716758"},{"Id":390619,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"00781716783"},{"Id":390620,"FormularyType":"OHP","DrugName":"AZELAIC ACID GEL 15%","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060010004020","GenericName":"AZELAIC ACID GEL 15%","NDC":"00781717250"},{"Id":390621,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"00781717770"},{"Id":390622,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"00781717775"},{"Id":390623,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"00781717785"},{"Id":390624,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"00781729685"},{"Id":390625,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00781751514"},{"Id":390626,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"00781751587"},{"Id":390627,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00781751614"},{"Id":390628,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"00781751687"},{"Id":390629,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"00781751714"},{"Id":390630,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"00781751787"},{"Id":390631,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"00781808532"},{"Id":390632,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"00781808692"},{"Id":390633,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"00781808926"},{"Id":390634,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"00781808931"},{"Id":390635,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"00781809003"},{"Id":390636,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"00781809031"},{"Id":390637,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000340","GenericName":"AZITHROMYCIN TAB 600 MG","NDC":"00781809131"},{"Id":390638,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"00781921090"},{"Id":390639,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"00781921095"},{"Id":390640,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"00781921390"},{"Id":390641,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"00781921395"},{"Id":390642,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"00781921491"},{"Id":390643,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"00781921495"},{"Id":390644,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"00781926185"},{"Id":390645,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"00781926195"},{"Id":390646,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"00781927380"},{"Id":390647,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"00781927395"},{"Id":390648,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"00781940485"},{"Id":390649,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"00781940495"},{"Id":390650,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"00781940880"},{"Id":390651,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"00781940895"},{"Id":390652,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"00781940946"},{"Id":390653,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"00781940995"},{"Id":390654,"FormularyType":"OHP","DrugName":"SYRPALTA SYP","DosageForm":"SYRP - Syrup","Strength":"85","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"00802392016"},{"Id":390655,"FormularyType":"OHP","DrugName":"SYRPALTA SYP","DosageForm":"SYRP - Syrup","Strength":"83","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"00802392716"},{"Id":390656,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"00832003800"},{"Id":390657,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"00832003801"},{"Id":390658,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"00832003810"},{"Id":390659,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"00832003850"},{"Id":390660,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"00832003889"},{"Id":390661,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"00832035611"},{"Id":390662,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"00832035711"},{"Id":390663,"FormularyType":"OHP","DrugName":"NYAMYC POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"00832046515"},{"Id":390664,"FormularyType":"OHP","DrugName":"NYAMYC POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"00832046530"},{"Id":390665,"FormularyType":"OHP","DrugName":"NYAMYC POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"00832046560"},{"Id":390666,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100310","GenericName":"BETHANECHOL CHLORIDE TAB 5 MG","NDC":"00832051000"},{"Id":390667,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"00832051100"},{"Id":390668,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"00832051101"},{"Id":390669,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"00832051189"},{"Id":390670,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"00832051200"},{"Id":390671,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"00832051201"},{"Id":390672,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"00832051289"},{"Id":390673,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100340","GenericName":"BETHANECHOL CHLORIDE TAB 50 MG","NDC":"00832051300"},{"Id":390674,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"00832058011"},{"Id":390675,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"00832058111"},{"Id":390676,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"00832059530"},{"Id":390677,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"00832111260"},{"Id":390678,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"00832111360"},{"Id":390679,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00832112005"},{"Id":390680,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00832112035"},{"Id":390681,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00832112065"},{"Id":390682,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"00832112089"},{"Id":390683,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL PUMP 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004040","GenericName":"TESTOSTERONE TD GEL 12.5 MG/ACT (1%)","NDC":"00832112140"},{"Id":390684,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL PUMP 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004040","GenericName":"TESTOSTERONE TD GEL 12.5 MG/ACT (1%)","NDC":"00832112142"},{"Id":390685,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"00832121100"},{"Id":390686,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"00832121110"},{"Id":390687,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"00832121200"},{"Id":390688,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"00832121210"},{"Id":390689,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"00832121300"},{"Id":390690,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"00832121310"},{"Id":390691,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"00832121400"},{"Id":390692,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"00832121410"},{"Id":390693,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"00832121500"},{"Id":390694,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"00832121510"},{"Id":390695,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"00832121600"},{"Id":390696,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"00832121610"},{"Id":390697,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"00832121700"},{"Id":390698,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"00832121800"},{"Id":390699,"FormularyType":"OHP","DrugName":"JANTOVEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"00832121900"},{"Id":390700,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"00832125011"},{"Id":390701,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"00832125030"},{"Id":390702,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"00832135811"},{"Id":390703,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"00832135911"},{"Id":390704,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"00832141003"},{"Id":390705,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"00832143075"},{"Id":390706,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00832532410"},{"Id":390707,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"00832532411"},{"Id":390708,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00832532510"},{"Id":390709,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00832532511"},{"Id":390710,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"00832532515"},{"Id":390711,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"00832602211"},{"Id":390712,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"00832602311"},{"Id":390713,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"00832602411"},{"Id":390714,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"00832604510"},{"Id":390715,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"00832604515"},{"Id":390716,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"00832604550"},{"Id":390717,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"00832605612"},{"Id":390718,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"00832607211"},{"Id":390719,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"00832607311"},{"Id":390720,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00832830130"},{"Id":390721,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"00832830189"},{"Id":390722,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00832830230"},{"Id":390723,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"00832830289"},{"Id":390724,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00832830330"},{"Id":390725,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"00832830389"},{"Id":390726,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00832830430"},{"Id":390727,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"00832830489"},{"Id":390728,"FormularyType":"OHP","DrugName":"COMPLEX ESSE POW MSD","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847059722"},{"Id":390729,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095012"},{"Id":390730,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095022"},{"Id":390731,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095032"},{"Id":390732,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095042"},{"Id":390733,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095082"},{"Id":390734,"FormularyType":"OHP","DrugName":"PHENYLADE POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095112"},{"Id":390735,"FormularyType":"OHP","DrugName":"PHENYLADE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095222"},{"Id":390736,"FormularyType":"OHP","DrugName":"PHENYLADE POW ORANGE C","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095332"},{"Id":390737,"FormularyType":"OHP","DrugName":"PHENYLADE POW STRAWBER","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095442"},{"Id":390738,"FormularyType":"OHP","DrugName":"PHENYLADE60 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095602"},{"Id":390739,"FormularyType":"OHP","DrugName":"PHENYLADE60 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"00847095622"},{"Id":390740,"FormularyType":"OHP","DrugName":"PHENYLADE LIQ RTD","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"00847095668"},{"Id":390741,"FormularyType":"OHP","DrugName":"CERASPORT SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00851050012"},{"Id":390742,"FormularyType":"OHP","DrugName":"CERASPORT SOL EX1","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00851050013"},{"Id":390743,"FormularyType":"OHP","DrugName":"CERALYTE 70 SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"00851050030"},{"Id":390744,"FormularyType":"OHP","DrugName":"CITROMA SOL LEMONY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00869016638"},{"Id":390745,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"00869083143"},{"Id":390746,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"00869420610"},{"Id":390747,"FormularyType":"OHP","DrugName":"UREACIN-20 CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"00884044904"},{"Id":390748,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"00904001224"},{"Id":390749,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"00904001259"},{"Id":390750,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"00904001261"},{"Id":390751,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"00904001280"},{"Id":390752,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 450MG","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"00904027746"},{"Id":390753,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 450MG","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"00904027760"},{"Id":390754,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"00904042804"},{"Id":390755,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"00904042806"},{"Id":390756,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"00904043004"},{"Id":390757,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"00904043006"},{"Id":390758,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"00904043095"},{"Id":390759,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00904078816"},{"Id":390760,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"00904188361"},{"Id":390761,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"00904188372"},{"Id":390762,"FormularyType":"OHP","DrugName":"MAPAP CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000115","GenericName":"ACETAMINOPHEN CAP 500 MG","NDC":"00904198760"},{"Id":390763,"FormularyType":"OHP","DrugName":"TRI-BUFF ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64109902040320","GenericName":"ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG","NDC":"00904201559"},{"Id":390764,"FormularyType":"OHP","DrugName":"DRIMINATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"00904205159"},{"Id":390765,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"00904216680"},{"Id":390766,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"00904227260"},{"Id":390767,"FormularyType":"OHP","DrugName":"FIBER TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"00904250091"},{"Id":390768,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00904261460"},{"Id":390769,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000505","GenericName":"CARBAMAZEPINE CHEW TAB 100 MG","NDC":"00904385461"},{"Id":390770,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00904404073"},{"Id":390771,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"00904423960"},{"Id":390772,"FormularyType":"OHP","DrugName":"SLEEP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"00904427451"},{"Id":390773,"FormularyType":"OHP","DrugName":"SUDOGEST TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00904505359"},{"Id":390774,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"00904525944"},{"Id":390775,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00904530909"},{"Id":390776,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00904530920"},{"Id":390777,"FormularyType":"OHP","DrugName":"PRENATAL TAB 27-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"00904531346"},{"Id":390778,"FormularyType":"OHP","DrugName":"PRENATAL TAB 27-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"00904531360"},{"Id":390779,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"00904544861"},{"Id":390780,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00904546052"},{"Id":390781,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00904546072"},{"Id":390782,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00904546080"},{"Id":390783,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"00904546092"},{"Id":390784,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"00904546335"},{"Id":390785,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"00904552261"},{"Id":390786,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"00904552361"},{"Id":390787,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"00904552461"},{"Id":390788,"FormularyType":"OHP","DrugName":"HEARTBURN TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00904552952"},{"Id":390789,"FormularyType":"OHP","DrugName":"HEARTBURN TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"00904552987"},{"Id":390790,"FormularyType":"OHP","DrugName":"BANOPHEN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00904555124"},{"Id":390791,"FormularyType":"OHP","DrugName":"BANOPHEN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"00904555159"},{"Id":390792,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"00904557720"},{"Id":390793,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"00904563889"},{"Id":390794,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"00904563943"},{"Id":390795,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"00904563946"},{"Id":390796,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"00904563948"},{"Id":390797,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"00904564046"},{"Id":390798,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"00904564048"},{"Id":390799,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"00904564089"},{"Id":390800,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"00904564289"},{"Id":390801,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00904569915"},{"Id":390802,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00904578017"},{"Id":390803,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00904578051"},{"Id":390804,"FormularyType":"OHP","DrugName":"MAPAP CHILD CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"00904579146"},{"Id":390805,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"00904582360"},{"Id":390806,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"00904585340"},{"Id":390807,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"00904585360"},{"Id":390808,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"00904585361"},{"Id":390809,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"00904585440"},{"Id":390810,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"00904585460"},{"Id":390811,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"00904585461"},{"Id":390812,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"00904585540"},{"Id":390813,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"00904585560"},{"Id":390814,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"00904585561"},{"Id":390815,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"00904589161"},{"Id":390816,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"00904589261"},{"Id":390817,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"00904589361"},{"Id":390818,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"00904592161"},{"Id":390819,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"00904592261"},{"Id":390820,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"00904595961"},{"Id":390821,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"00904598348"},{"Id":390822,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"00904598426"},{"Id":390823,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"00904598463"},{"Id":390824,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"00904608261"},{"Id":390825,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"00904617250"},{"Id":390826,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"00904617261"},{"Id":390827,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"00904622106"},{"Id":390828,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"00904622161"},{"Id":390829,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"00904629006"},{"Id":390830,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"00904629061"},{"Id":390831,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"00904629106"},{"Id":390832,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"00904629161"},{"Id":390833,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"00904629206"},{"Id":390834,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"00904629261"},{"Id":390835,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"00904629304"},{"Id":390836,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"00904632206"},{"Id":390837,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"00904632261"},{"Id":390838,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"00904632361"},{"Id":390839,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"00904632461"},{"Id":390840,"FormularyType":"OHP","DrugName":"SUDOGEST MAX TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00904633724"},{"Id":390841,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"00904635161"},{"Id":390842,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"00904635261"},{"Id":390843,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"00904635361"},{"Id":390844,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"00904636961"},{"Id":390845,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"00904637061"},{"Id":390846,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00904637161"},{"Id":390847,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"00904637361"},{"Id":390848,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"00904637461"},{"Id":390849,"FormularyType":"OHP","DrugName":"FERATE TAB 27MG","DosageForm":"TABS - Tablet","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"00904640360"},{"Id":390850,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00904640761"},{"Id":390851,"FormularyType":"OHP","DrugName":"CALC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"00904641292"},{"Id":390852,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"00904641861"},{"Id":390853,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"00904644961"},{"Id":390854,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"00904645061"},{"Id":390855,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"00904647461"},{"Id":390856,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"00904647761"},{"Id":390857,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"00904647861"},{"Id":390858,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"00904650006"},{"Id":390859,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"00904650061"},{"Id":390860,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"00904650106"},{"Id":390861,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"00904650161"},{"Id":390862,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"00904650506"},{"Id":390863,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"00904650561"},{"Id":390864,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"00904650606"},{"Id":390865,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"00904650661"},{"Id":390866,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"00904655161"},{"Id":390867,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"00904655261"},{"Id":390868,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"00904655304"},{"Id":390869,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"00904655761"},{"Id":390870,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"00904655861"},{"Id":390871,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"00904655961"},{"Id":390872,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"00904656061"},{"Id":390873,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"00904656460"},{"Id":390874,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"00904656507"},{"Id":390875,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"00904656561"},{"Id":390876,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"00904657004"},{"Id":390877,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"00904657006"},{"Id":390878,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"00904657061"},{"Id":390879,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"00904657261"},{"Id":390880,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"00904657561"},{"Id":390881,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"00904658168"},{"Id":390882,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"00904658304"},{"Id":390883,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"00904659604"},{"Id":390884,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"00904661861"},{"Id":390885,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"00904661961"},{"Id":390886,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"00904662061"},{"Id":390887,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"00904662104"},{"Id":390888,"FormularyType":"OHP","DrugName":"PYRIDOSTIGM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100305","GenericName":"PYRIDOSTIGMINE BROMIDE TAB 60 MG","NDC":"00904662261"},{"Id":390889,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"00904662361"},{"Id":390890,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"00904662461"},{"Id":390891,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"00904663761"},{"Id":390892,"FormularyType":"OHP","DrugName":"MAPAP CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"00904664524"},{"Id":390893,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"00904666245"},{"Id":390894,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"00904666361"},{"Id":390895,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"00904666561"},{"Id":390896,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"00904666661"},{"Id":390897,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"00904666761"},{"Id":390898,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"00904667104"},{"Id":390899,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"00904667106"},{"Id":390900,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00904667840"},{"Id":390901,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"00904670461"},{"Id":390902,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671740"},{"Id":390903,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671741"},{"Id":390904,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671743"},{"Id":390905,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671746"},{"Id":390906,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671760"},{"Id":390907,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671772"},{"Id":390908,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904671786"},{"Id":390909,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904672024"},{"Id":390910,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904672040"},{"Id":390911,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904672051"},{"Id":390912,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904672059"},{"Id":390913,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904672060"},{"Id":390914,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904672080"},{"Id":390915,"FormularyType":"OHP","DrugName":"SUDOGEST TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100310","GenericName":"PSEUDOEPHEDRINE HCL TAB 60 MG","NDC":"00904672846"},{"Id":390916,"FormularyType":"OHP","DrugName":"SUDOGEST TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100310","GenericName":"PSEUDOEPHEDRINE HCL TAB 60 MG","NDC":"00904672852"},{"Id":390917,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904673059"},{"Id":390918,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904673060"},{"Id":390919,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904673061"},{"Id":390920,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"00904673080"},{"Id":390921,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904674724"},{"Id":390922,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904674740"},{"Id":390923,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904674751"},{"Id":390924,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904674759"},{"Id":390925,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904674770"},{"Id":390926,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904674780"},{"Id":390927,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00904674817"},{"Id":390928,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00904674860"},{"Id":390929,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"00904674880"},{"Id":390930,"FormularyType":"OHP","DrugName":"DOK TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"00904675060"},{"Id":390931,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00904675180"},{"Id":390932,"FormularyType":"OHP","DrugName":"SUDOGEST 12 TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00904675415"},{"Id":390933,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"00904676520"},{"Id":390934,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"00904676720"},{"Id":390935,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"00904677361"},{"Id":390936,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"00904678370"},{"Id":390937,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"00904678504"},{"Id":390938,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"00904678561"},{"Id":390939,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"00904678604"},{"Id":390940,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"00904678661"},{"Id":390941,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00904679480"},{"Id":390942,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00904679489"},{"Id":390943,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"00904679604"},{"Id":390944,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"00904679610"},{"Id":390945,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"00904679761"},{"Id":390946,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"00904679861"},{"Id":390947,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"00904679961"},{"Id":390948,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"00904680806"},{"Id":390949,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"00904680861"},{"Id":390950,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"00904681706"},{"Id":390951,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"00904681761"},{"Id":390952,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"00904681806"},{"Id":390953,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"00904681861"},{"Id":390954,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"00904681907"},{"Id":390955,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"00904682104"},{"Id":390956,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"00904682207"},{"Id":390957,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"00904682361"},{"Id":390958,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00904682892"},{"Id":390959,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"00904682894"},{"Id":390960,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"00904683006"},{"Id":390961,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"00904683061"},{"Id":390962,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"00904683204"},{"Id":390963,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000105","GenericName":"FLUCYTOSINE CAP 250 MG","NDC":"00904683407"},{"Id":390964,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000110","GenericName":"FLUCYTOSINE CAP 500 MG","NDC":"00904683507"},{"Id":390965,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00904685272"},{"Id":390966,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00904685289"},{"Id":390967,"FormularyType":"OHP","DrugName":"TRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21708080000110","GenericName":"TRETINOIN CAP 10 MG","NDC":"00904686704"},{"Id":390968,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"00904687045"},{"Id":390969,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"00904687204"},{"Id":390970,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"00904687404"},{"Id":390971,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"00904687406"},{"Id":390972,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"00904688210"},{"Id":390973,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 200MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006920","GenericName":"CARBAMAZEPINE CAP ER 12HR 200 MG","NDC":"00904688504"},{"Id":390974,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"00904688806"},{"Id":390975,"FormularyType":"OHP","DrugName":"URSODIOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000325","GenericName":"URSODIOL TAB 250 MG","NDC":"00904689004"},{"Id":390976,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"00904690004"},{"Id":390977,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"00904690061"},{"Id":390978,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"00904690104"},{"Id":390979,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"00904690204"},{"Id":390980,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100310","GenericName":"PSEUDOEPHEDRINE HCL TAB 60 MG","NDC":"00904690706"},{"Id":390981,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"00904691461"},{"Id":390982,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"00904691761"},{"Id":390983,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"00904692361"},{"Id":390984,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"00904692761"},{"Id":390985,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"00904692861"},{"Id":390986,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"00904692961"},{"Id":390987,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"00904693126"},{"Id":390988,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"00904693176"},{"Id":390989,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"00904693181"},{"Id":390990,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"00904693186"},{"Id":390991,"FormularyType":"OHP","DrugName":"HYDROXYUREA CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700030000105","GenericName":"HYDROXYUREA CAP 500 MG","NDC":"00904693961"},{"Id":390992,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"00904694804"},{"Id":390993,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"00904694961"},{"Id":390994,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"00904695061"},{"Id":390995,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"00904695161"},{"Id":390996,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"00904695261"},{"Id":390997,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"00904695361"},{"Id":390998,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"00904695461"},{"Id":390999,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"00904695561"},{"Id":391000,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"00904695661"},{"Id":391001,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"00904695761"},{"Id":391002,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"00904696661"},{"Id":391003,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"00904698761"},{"Id":391004,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"00904698861"},{"Id":391005,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"00904699061"},{"Id":391006,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"00904699104"},{"Id":391007,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"00904699161"},{"Id":391008,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"00904699261"},{"Id":391009,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"00904700061"},{"Id":391010,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"00904700161"},{"Id":391011,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"00904700261"},{"Id":391012,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"00904700304"},{"Id":391013,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"00904700404"},{"Id":391014,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"00904700504"},{"Id":391015,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"00904700906"},{"Id":391016,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"00904701006"},{"Id":391017,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904701416"},{"Id":391018,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904701420"},{"Id":391019,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"00904701604"},{"Id":391020,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"00904701606"},{"Id":391021,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"00904701661"},{"Id":391022,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"00904702061"},{"Id":391023,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"00904702161"},{"Id":391024,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"00904702261"},{"Id":391025,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"00904702367"},{"Id":391026,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"00904702404"},{"Id":391027,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"00904702661"},{"Id":391028,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"00904702761"},{"Id":391029,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00904703580"},{"Id":391030,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"00904703587"},{"Id":391031,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"00904703604"},{"Id":391032,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"00904704161"},{"Id":391033,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"00904704206"},{"Id":391034,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"00904704240"},{"Id":391035,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"00904704259"},{"Id":391036,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"00904704261"},{"Id":391037,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"00904704606"},{"Id":391038,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"00904704661"},{"Id":391039,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"00904704761"},{"Id":391040,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"00904704861"},{"Id":391041,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"00904704961"},{"Id":391042,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"00904705699"},{"Id":391043,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"00904705761"},{"Id":391044,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"00904705861"},{"Id":391045,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"00904705952"},{"Id":391046,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"00904706561"},{"Id":391047,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"00904707861"},{"Id":391048,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"00904708106"},{"Id":391049,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"00904708161"},{"Id":391050,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"00904708204"},{"Id":391051,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"00904708206"},{"Id":391052,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"00904709061"},{"Id":391053,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"00904709361"},{"Id":391054,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"00904709461"},{"Id":391055,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"00904709561"},{"Id":391056,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"00904709661"},{"Id":391057,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"00904709761"},{"Id":391058,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"00904710310"},{"Id":391059,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"00904710561"},{"Id":391060,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"00904710661"},{"Id":391061,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"00904710761"},{"Id":391062,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"00904710861"},{"Id":391063,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"00904711906"},{"Id":391064,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"00904711961"},{"Id":391065,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"00904712004"},{"Id":391066,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"00904712361"},{"Id":391067,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"00904712461"},{"Id":391068,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"00904712561"},{"Id":391069,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"00904712661"},{"Id":391070,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"00904714004"},{"Id":391071,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"00904714110"},{"Id":391072,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"00904714212"},{"Id":391073,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"00904714361"},{"Id":391074,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000110","GenericName":"DRONABINOL CAP 2.5 MG","NDC":"00904714461"},{"Id":391075,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000115","GenericName":"DRONABINOL CAP 5 MG","NDC":"00904714504"},{"Id":391076,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"00904714904"},{"Id":391077,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"00904714910"},{"Id":391078,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"00904715361"},{"Id":391079,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"00904715404"},{"Id":391080,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"00904715504"},{"Id":391081,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"00904715661"},{"Id":391082,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"00904716161"},{"Id":391083,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"00904716261"},{"Id":391084,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"00904716361"},{"Id":391085,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"00904716461"},{"Id":391086,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"00904717207"},{"Id":391087,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"00904717761"},{"Id":391088,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"00904717861"},{"Id":391089,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"00904718061"},{"Id":391090,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"00904718361"},{"Id":391091,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"00904718761"},{"Id":391092,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"00904718861"},{"Id":391093,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"00904719106"},{"Id":391094,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"00904719204"},{"Id":391095,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"00904719260"},{"Id":391096,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00904719306"},{"Id":391097,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"00904719361"},{"Id":391098,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"00904719461"},{"Id":391099,"FormularyType":"OHP","DrugName":"PHENYTOIN CHW 50MG","DosageForm":"CHEW - Tablet Chewable","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030000505","GenericName":"PHENYTOIN CHEW TAB 50 MG","NDC":"00904719907"},{"Id":391100,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"00904720061"},{"Id":391101,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"00904720806"},{"Id":391102,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"00904720861"},{"Id":391103,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100105","GenericName":"DANTROLENE SODIUM CAP 25 MG","NDC":"00904721104"},{"Id":391104,"FormularyType":"OHP","DrugName":"ACAMPRO CAL TAB 333MG","DosageForm":"TBEC - Tablet DR","Strength":"333","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802010200620","GenericName":"ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","NDC":"00904721304"},{"Id":391105,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"00904721661"},{"Id":391106,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"00904721761"},{"Id":391107,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"00904721861"},{"Id":391108,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"00904721961"},{"Id":391109,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"00904722061"},{"Id":391110,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"00904722461"},{"Id":391111,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"00904722761"},{"Id":391112,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000105","GenericName":"NIFEDIPINE CAP 10 MG","NDC":"00904722961"},{"Id":391113,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100310","GenericName":"MEGESTROL ACETATE TAB 40 MG","NDC":"00904723661"},{"Id":391114,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"00904723860"},{"Id":391115,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"00904724361"},{"Id":391116,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"00904724395"},{"Id":391117,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"00904724468"},{"Id":391118,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"00904724568"},{"Id":391119,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"00904724668"},{"Id":391120,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"00904724768"},{"Id":391121,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"00904724804"},{"Id":391122,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00904725260"},{"Id":391123,"FormularyType":"OHP","DrugName":"SENNA-LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00904725261"},{"Id":391124,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"00904725280"},{"Id":391125,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"00904725304"},{"Id":391126,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"00904725368"},{"Id":391127,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"00904725435"},{"Id":391128,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"00904725468"},{"Id":391129,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"00904725510"},{"Id":391130,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"00904725568"},{"Id":391131,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"00904726161"},{"Id":391132,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"00904726261"},{"Id":391133,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"00904726361"},{"Id":391134,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00904726592"},{"Id":391135,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00904726593"},{"Id":391136,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00904726594"},{"Id":391137,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"00904726661"},{"Id":391138,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"00904726761"},{"Id":391139,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"00904727670"},{"Id":391140,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"00904727692"},{"Id":391141,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00904727870"},{"Id":391142,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 100/10ML","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00904727966"},{"Id":391143,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 100/10ML","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"00904727972"},{"Id":391144,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"00904728060"},{"Id":391145,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"00904728080"},{"Id":391146,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"00904728160"},{"Id":391147,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"00904728180"},{"Id":391148,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"00904728306"},{"Id":391149,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"00904728361"},{"Id":391150,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"00904728861"},{"Id":391151,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"00904728961"},{"Id":391152,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"00904729061"},{"Id":391153,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"00904730461"},{"Id":391154,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"00904730661"},{"Id":391155,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"00904730761"},{"Id":391156,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"00904730961"},{"Id":391157,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"00904731061"},{"Id":391158,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"00904731161"},{"Id":391159,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"00904731261"},{"Id":391160,"FormularyType":"OHP","DrugName":"BUDESONIDE CAP 3MG DR","DosageForm":"CPEP - Capsule DR Part","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100012006720","GenericName":"BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","NDC":"00904731310"},{"Id":391161,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00904731427"},{"Id":391162,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"00904731561"},{"Id":391163,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"00904731706"},{"Id":391164,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"00904731761"},{"Id":391165,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904731941"},{"Id":391166,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904731970"},{"Id":391167,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904732002"},{"Id":391168,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904732071"},{"Id":391169,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650/20.3","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904732103"},{"Id":391170,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650/20.3","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"00904732176"},{"Id":391171,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"00904733661"},{"Id":391172,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"00904733706"},{"Id":391173,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"00904733761"},{"Id":391174,"FormularyType":"OHP","DrugName":"LICE SHAMPOO SHA MAX STR","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"00904734920"},{"Id":391175,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"00904735006"},{"Id":391176,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"00904735061"},{"Id":391177,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"00904735104"},{"Id":391178,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"00904737261"},{"Id":391179,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"00904737561"},{"Id":391180,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"00904737661"},{"Id":391181,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"00904737880"},{"Id":391182,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"00904737940"},{"Id":391183,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"00904737980"},{"Id":391184,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"00904738106"},{"Id":391185,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"00904738206"},{"Id":391186,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"00904738361"},{"Id":391187,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"00904739546"},{"Id":391188,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"00904739646"},{"Id":391189,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"00904739753"},{"Id":391190,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"00904739789"},{"Id":391191,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"00904739889"},{"Id":391192,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"00904740161"},{"Id":391193,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"00904740267"},{"Id":391194,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"00904740361"},{"Id":391195,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"00904740704"},{"Id":391196,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"00904740706"},{"Id":391197,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"00904740861"},{"Id":391198,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"00904740915"},{"Id":391199,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"00904741335"},{"Id":391200,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"00904741435"},{"Id":391201,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"00904741516"},{"Id":391202,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"00904741661"},{"Id":391203,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"00904741844"},{"Id":391204,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"00904742016"},{"Id":391205,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00904742646"},{"Id":391206,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00904742659"},{"Id":391207,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"00904743405"},{"Id":391208,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"00904743410"},{"Id":391209,"FormularyType":"OHP","DrugName":"SENNA/DSS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"00904744061"},{"Id":391210,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"00904744261"},{"Id":391211,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"00904744361"},{"Id":391212,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"00904744461"},{"Id":391213,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"00904744520"},{"Id":391214,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"00904744761"},{"Id":391215,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"00904744861"},{"Id":391216,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"00904744961"},{"Id":391217,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"00904745061"},{"Id":391218,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"00904745161"},{"Id":391219,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"00904745261"},{"Id":391220,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"00904745361"},{"Id":391221,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"00904745861"},{"Id":391222,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"00904745925"},{"Id":391223,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"00904745953"},{"Id":391224,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746146"},{"Id":391225,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746151"},{"Id":391226,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746180"},{"Id":391227,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746187"},{"Id":391228,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746243"},{"Id":391229,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746260"},{"Id":391230,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"00904746273"},{"Id":391231,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00904746341"},{"Id":391232,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00904746368"},{"Id":391233,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00904746464"},{"Id":391234,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"00904746466"},{"Id":391235,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"00904746661"},{"Id":391236,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"00904746761"},{"Id":391237,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"00904746806"},{"Id":391238,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"00904746861"},{"Id":391239,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00904747001"},{"Id":391240,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00904747018"},{"Id":391241,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00904747056"},{"Id":391242,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"00904747072"},{"Id":391243,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"00904747261"},{"Id":391244,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"00904748004"},{"Id":391245,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"00904748061"},{"Id":391246,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"00904748303"},{"Id":391247,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"00904748389"},{"Id":391248,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00904748602"},{"Id":391249,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00904748640"},{"Id":391250,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"00904748660"},{"Id":391251,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"00904749371"},{"Id":391252,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"00904749406"},{"Id":391253,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"00904749661"},{"Id":391254,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"00904750161"},{"Id":391255,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"00904750204"},{"Id":391256,"FormularyType":"OHP","DrugName":"FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"00904750313"},{"Id":391257,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"00904750604"},{"Id":391258,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"00904750761"},{"Id":391259,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"00904750930"},{"Id":391260,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"00904751061"},{"Id":391261,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"00904751161"},{"Id":391262,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"00904751961"},{"Id":391263,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"00904752061"},{"Id":391264,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"00904752161"},{"Id":391265,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"00904752208"},{"Id":391266,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"00904752308"},{"Id":391267,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"00904752408"},{"Id":391268,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"00904752841"},{"Id":391269,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"00904752894"},{"Id":391270,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00904753315"},{"Id":391271,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00904753320"},{"Id":391272,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"00904753904"},{"Id":391273,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"00904754210"},{"Id":391274,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"00904754361"},{"Id":391275,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"00904754961"},{"Id":391276,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"00904755261"},{"Id":391277,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"00904755361"},{"Id":391278,"FormularyType":"OHP","DrugName":"MAG/ALUM/SIM SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00904755762"},{"Id":391279,"FormularyType":"OHP","DrugName":"MAG/ALUM/SIM SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"00904755773"},{"Id":391280,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00904755966"},{"Id":391281,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00904755972"},{"Id":391282,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00904756041"},{"Id":391283,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"00904756070"},{"Id":391284,"FormularyType":"OHP","DrugName":"8HR ARTHRITS TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"00904756160"},{"Id":391285,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"00904756304"},{"Id":391286,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00904756462"},{"Id":391287,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"00904756473"},{"Id":391288,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"00904756541"},{"Id":391289,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"00904756570"},{"Id":391290,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400/10ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00904757718"},{"Id":391291,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400/10ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"00904757772"},{"Id":391292,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"00904758004"},{"Id":391293,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"00904758104"},{"Id":391294,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"00904758204"},{"Id":391295,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"00904758361"},{"Id":391296,"FormularyType":"OHP","DrugName":"FEROSUL TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00904759060"},{"Id":391297,"FormularyType":"OHP","DrugName":"FEROSUL TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00904759080"},{"Id":391298,"FormularyType":"OHP","DrugName":"FEROSUL TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00904759160"},{"Id":391299,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00904759161"},{"Id":391300,"FormularyType":"OHP","DrugName":"FEROSUL TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00904759180"},{"Id":391301,"FormularyType":"OHP","DrugName":"FEROSUL TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"00904759182"},{"Id":391302,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"00904772861"},{"Id":391303,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"00904773445"},{"Id":391304,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904791251"},{"Id":391305,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904791259"},{"Id":391306,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"00904791461"},{"Id":391307,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00904880531"},{"Id":391308,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"00904880567"},{"Id":391309,"FormularyType":"OHP","DrugName":"ARALAST NP INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"ALPHA-PROTEINASE INHIBITOR (HUMAN)","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45100010102110","GenericName":"ALPHA1-PROTEINASE INHIBITOR (HUMAN) FOR IV SOLN 500 MG","NDC":"00944281401"},{"Id":391310,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"00955100401"},{"Id":391311,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"00955100410"},{"Id":391312,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"00955100601"},{"Id":391313,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"00955100610"},{"Id":391314,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"00955100801"},{"Id":391315,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"00955100810"},{"Id":391316,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"00955101010"},{"Id":391317,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"00955101201"},{"Id":391318,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"00955101210"},{"Id":391319,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"00955101510"},{"Id":391320,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 300/3ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101020102050","GenericName":"ENOXAPARIN SODIUM INJ 300 MG/3ML","NDC":"00955101601"},{"Id":391321,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100340","GenericName":"SEVELAMER HCL TAB 800 MG","NDC":"00955104818"},{"Id":391322,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"00955105201"},{"Id":391323,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"00955105290"},{"Id":391324,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"00955105401"},{"Id":391325,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"00955105490"},{"Id":391326,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00990613803"},{"Id":391327,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00990613903"},{"Id":391328,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002050","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/100ML","NDC":"00990707426"},{"Id":391329,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002055","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/50ML","NDC":"00990707514"},{"Id":391330,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002060","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/100ML","NDC":"00990707526"},{"Id":391331,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002070","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/50ML","NDC":"00990707714"},{"Id":391332,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 40MEQ","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002075","GenericName":"POTASSIUM CHLORIDE INJ 40 MEQ/100ML","NDC":"00990707726"},{"Id":391333,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00990711807"},{"Id":391334,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002060","GenericName":"DEXTROSE INJ 70%","NDC":"00990712007"},{"Id":391335,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00990713809"},{"Id":391336,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00990713909"},{"Id":391337,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00990713936"},{"Id":391338,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00990773036"},{"Id":391339,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00990773037"},{"Id":391340,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002060","GenericName":"DEXTROSE INJ 70%","NDC":"00990791819"},{"Id":391341,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792202"},{"Id":391342,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792203"},{"Id":391343,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792209"},{"Id":391344,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792255"},{"Id":391345,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792261"},{"Id":391346,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792313"},{"Id":391347,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792320"},{"Id":391348,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792323"},{"Id":391349,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792336"},{"Id":391350,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"00990792337"},{"Id":391351,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00990792602"},{"Id":391352,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00990792603"},{"Id":391353,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"00990792609"},{"Id":391354,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00990793002"},{"Id":391355,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00990793003"},{"Id":391356,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00990793009"},{"Id":391357,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002025","GenericName":"DEXTROSE INJ 20%","NDC":"00990793519"},{"Id":391358,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 50%","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"00990793619"},{"Id":391359,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 40%","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002045","GenericName":"DEXTROSE INJ 40%","NDC":"00990793719"},{"Id":391360,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"00990793819"},{"Id":391361,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00990794103"},{"Id":391362,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"O","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"00990794109"},{"Id":391363,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00990797205"},{"Id":391364,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00990797207"},{"Id":391365,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"00990797208"},{"Id":391366,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00990797305"},{"Id":391367,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00990797307"},{"Id":391368,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"00990797308"},{"Id":391369,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798302"},{"Id":391370,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798303"},{"Id":391371,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798309"},{"Id":391372,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798355"},{"Id":391373,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798361"},{"Id":391374,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798413"},{"Id":391375,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798420"},{"Id":391376,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798423"},{"Id":391377,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798436"},{"Id":391378,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"00990798437"},{"Id":391379,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00990798502"},{"Id":391380,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00990798503"},{"Id":391381,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"00990798509"},{"Id":391382,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"00990799009"},{"Id":391383,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 30%","DosageForm":"SOLN - Solution","Strength":"30","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002035","GenericName":"DEXTROSE INJ 30%","NDC":"00990800415"},{"Id":391384,"FormularyType":"OHP","DrugName":"CHILDRENS CHW PEPTO","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000504","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG","NDC":"01490003966"},{"Id":391385,"FormularyType":"OHP","DrugName":"DUREX MIS TROPICAL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"02340009000"},{"Id":391386,"FormularyType":"OHP","DrugName":"DUREX EXTRA MIS SENSITIV","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"02340012900"},{"Id":391387,"FormularyType":"OHP","DrugName":"DUREX EXTRA MIS SENSITIV","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"02340024100"},{"Id":391388,"FormularyType":"OHP","DrugName":"DUREX EXTRA MIS SENSITIV","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"02340030271"},{"Id":391389,"FormularyType":"OHP","DrugName":"DUREX EXTRA MIS SENSITIV","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"02340099552"},{"Id":391390,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"03573015331"},{"Id":391391,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"03573015334"},{"Id":391392,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"03573015337"},{"Id":391393,"FormularyType":"OHP","DrugName":"SYRG/NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"03999060069"},{"Id":391394,"FormularyType":"OHP","DrugName":"SYRG/NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"03999060071"},{"Id":391395,"FormularyType":"OHP","DrugName":"SYRG/NEEDLE MIS 29GX12.5","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"03999060072"},{"Id":391396,"FormularyType":"OHP","DrugName":"SYRG/NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"03999060073"},{"Id":391397,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"03999060077"},{"Id":391398,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"03999060078"},{"Id":391399,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"03999060079"},{"Id":391400,"FormularyType":"OHP","DrugName":"AERCHMBR Z- MIS STAT PLS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351078710"},{"Id":391401,"FormularyType":"OHP","DrugName":"AERCHMBR Z- MIS STAT PLS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351079710"},{"Id":391402,"FormularyType":"OHP","DrugName":"AERCHMBR Z- MIS STAT PLS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351079750"},{"Id":391403,"FormularyType":"OHP","DrugName":"AEROCHAMBER MIS PLUS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351079810"},{"Id":391404,"FormularyType":"OHP","DrugName":"AEROCHAMBER MIS PLUS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351079850"},{"Id":391405,"FormularyType":"OHP","DrugName":"AERCHMBR Z- MIS STAT PLS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351080710"},{"Id":391406,"FormularyType":"OHP","DrugName":"AERCHMBR Z- MIS STAT PLS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351088710"},{"Id":391407,"FormularyType":"OHP","DrugName":"TRUZONE PEAK MIS FLOW MTR","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"04351096510"},{"Id":391408,"FormularyType":"OHP","DrugName":"AEROCHAMBER MIS MV","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351098510"},{"Id":391409,"FormularyType":"OHP","DrugName":"AEROCHAMBER MIS CHAMBER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"04351098810"},{"Id":391410,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"04903569960"},{"Id":391411,"FormularyType":"OHP","DrugName":"VITAMIN D-3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"05388000924"},{"Id":391412,"FormularyType":"OHP","DrugName":"D3 MAXIMUM CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"05388000927"},{"Id":391413,"FormularyType":"OHP","DrugName":"GLUCOSE GEL 40%","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"05388019332"},{"Id":391414,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"05388062808"},{"Id":391415,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"05388062809"},{"Id":391416,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"05388062812"},{"Id":391417,"FormularyType":"OHP","DrugName":"VITAMIN D-3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"05388062842"},{"Id":391418,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"05388081765"},{"Id":391419,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"05388098775"},{"Id":391420,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"05388098776"},{"Id":391421,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"05388098777"},{"Id":391422,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"05388098778"},{"Id":391423,"FormularyType":"OHP","DrugName":"EQ CALCIUM TAB CITR+D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"05388099500"},{"Id":391424,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"05388099945"},{"Id":391425,"FormularyType":"OHP","DrugName":"TRUSTX NON-9 MIS RIB/STUD","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083005"},{"Id":391426,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083010"},{"Id":391427,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083015"},{"Id":391428,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083020"},{"Id":391429,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083025"},{"Id":391430,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS EX STR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083027"},{"Id":391431,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083030"},{"Id":391432,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083035"},{"Id":391433,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083040"},{"Id":391434,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083045"},{"Id":391435,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS COLORS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083047"},{"Id":391436,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS NON-LUB","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632083050"},{"Id":391437,"FormularyType":"OHP","DrugName":"TRUSTEX/RIA MIS NON-LUB","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632083055"},{"Id":391438,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS RIB/STUD","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083060"},{"Id":391439,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS RIB/STUD","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083065"},{"Id":391440,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083067"},{"Id":391441,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083087"},{"Id":391442,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS EX LARGE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083137"},{"Id":391443,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS EX LARGE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083157"},{"Id":391444,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083177"},{"Id":391445,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083197"},{"Id":391446,"FormularyType":"OHP","DrugName":"NATURAL COND MIS + LUBE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083220"},{"Id":391447,"FormularyType":"OHP","DrugName":"NATURAL COND MIS + LUBE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083225"},{"Id":391448,"FormularyType":"OHP","DrugName":"COLOR CONDOM MIS + LUBE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083240"},{"Id":391449,"FormularyType":"OHP","DrugName":"COLOR CONDOM MIS + LUBE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632083245"},{"Id":391450,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS MINT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084005"},{"Id":391451,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS VANILLA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084010"},{"Id":391452,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS STRWBRY","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084015"},{"Id":391453,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS CHOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084020"},{"Id":391454,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS BANANA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084025"},{"Id":391455,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS GRAPE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084030"},{"Id":391456,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS COLA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084035"},{"Id":391457,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS ASSORTED","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084040"},{"Id":391458,"FormularyType":"OHP","DrugName":"TRUSTEX MIS FLAVORS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632084140"},{"Id":391459,"FormularyType":"OHP","DrugName":"TRUSTEX MIS VANILLA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632084150"},{"Id":391460,"FormularyType":"OHP","DrugName":"TRUSTEX MIS STRWBRY","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632084152"},{"Id":391461,"FormularyType":"OHP","DrugName":"TRUSTEX MIS CHOCOLAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632084154"},{"Id":391462,"FormularyType":"OHP","DrugName":"TRUSTEX MIS BANANA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632084156"},{"Id":391463,"FormularyType":"OHP","DrugName":"TRUSTEX MIS MINT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"05632084158"},{"Id":391464,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS EX STR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632084240"},{"Id":391465,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086800"},{"Id":391466,"FormularyType":"OHP","DrugName":"FANTASY MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086805"},{"Id":391467,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086810"},{"Id":391468,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086815"},{"Id":391469,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS COLORS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086820"},{"Id":391470,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS COLORS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086825"},{"Id":391471,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086830"},{"Id":391472,"FormularyType":"OHP","DrugName":"FANTASY LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632086835"},{"Id":391473,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS COLORS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632088080"},{"Id":391474,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632088082"},{"Id":391475,"FormularyType":"OHP","DrugName":"KAMELEON MIS TRI-COLR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632089200"},{"Id":391476,"FormularyType":"OHP","DrugName":"KAMELEON LUB MIS COLORS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632089204"},{"Id":391477,"FormularyType":"OHP","DrugName":"TRUSTEX LUBR MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"05632098082"},{"Id":391478,"FormularyType":"OHP","DrugName":"DIATRUST KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"06121076304"},{"Id":391479,"FormularyType":"OHP","DrugName":"DIATRUST KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"06121076323"},{"Id":391480,"FormularyType":"OHP","DrugName":"JUICE/FIBRE LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"07249050101"},{"Id":391481,"FormularyType":"OHP","DrugName":"JUICE/FIBRE LIQ FT PUNCH","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"07249050102"},{"Id":391482,"FormularyType":"OHP","DrugName":"JUICE/FIBRE LIQ GRAPE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"07249050103"},{"Id":391483,"FormularyType":"OHP","DrugName":"JUICE/FIBRE LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"07249050104"},{"Id":391484,"FormularyType":"OHP","DrugName":"NUTRA/SHAKE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"07249080408"},{"Id":391485,"FormularyType":"OHP","DrugName":"EGG/PRO POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"07249091101"},{"Id":391486,"FormularyType":"OHP","DrugName":"CA CIT/VIT D TAB 315/200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"07610015832"},{"Id":391487,"FormularyType":"OHP","DrugName":"VITAMIN D-3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"07610016840"},{"Id":391488,"FormularyType":"OHP","DrugName":"VITAMIN D-3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"07610017840"},{"Id":391489,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"07610022640"},{"Id":391490,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"07610032024"},{"Id":391491,"FormularyType":"OHP","DrugName":"OYSTER CALC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"07610093040"},{"Id":391492,"FormularyType":"OHP","DrugName":"TOOMEY SYRIN MIS 70ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006370","GenericName":"SYRINGE (DISPOSABLE) 70 ML","NDC":"08011041170"},{"Id":391493,"FormularyType":"OHP","DrugName":"BULB IRR SYR MIS 60ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08011802055"},{"Id":391494,"FormularyType":"OHP","DrugName":"PISTON IRRIG MIS 60ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08011802065"},{"Id":391495,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 60ML/REG","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08080000555"},{"Id":391496,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 60ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08080000777"},{"Id":391497,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08080032010"},{"Id":391498,"FormularyType":"OHP","DrugName":"ARGYL SALINE SOL 100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"08080100000"},{"Id":391499,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08080100555"},{"Id":391500,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030056320","GenericName":"INSULIN SYRINGE (DISP) U-100 1 ML","NDC":"08080100707"},{"Id":391501,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08080100777"},{"Id":391502,"FormularyType":"OHP","DrugName":"140ML SYRING MIS LUER-LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006390","GenericName":"SYRINGE (DISPOSABLE) 140 ML","NDC":"08080114063"},{"Id":391503,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08080125058"},{"Id":391504,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08080125158"},{"Id":391505,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706340","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"08080126038"},{"Id":391506,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08080127012"},{"Id":391507,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08080128012"},{"Id":391508,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08080160405"},{"Id":391509,"FormularyType":"OHP","DrugName":"CURITY GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080180600"},{"Id":391510,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 20ML/LT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08080200055"},{"Id":391511,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 20ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08080200077"},{"Id":391512,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006312","GenericName":"SYRINGE (DISPOSABLE) 12 ML","NDC":"08080200777"},{"Id":391513,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126305","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 18 X 1\"","NDC":"08080202132"},{"Id":391514,"FormularyType":"OHP","DrugName":"CURITY GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080214600"},{"Id":391515,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126305","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 18 X 1\"","NDC":"08080218100"},{"Id":391516,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126325","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 20 X 1-1/2\"","NDC":"08080220112"},{"Id":391517,"FormularyType":"OHP","DrugName":"CURITY GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080225200"},{"Id":391518,"FormularyType":"OHP","DrugName":"CURITY AMD PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080250600"},{"Id":391519,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS REG TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08080300555"},{"Id":391520,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08080300777"},{"Id":391521,"FormularyType":"OHP","DrugName":"CURITY SPONG PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080304100"},{"Id":391522,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"08080320112"},{"Id":391523,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08080321100"},{"Id":391524,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08080321112"},{"Id":391525,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08080322100"},{"Id":391526,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08080322112"},{"Id":391527,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08080323100"},{"Id":391528,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08080325058"},{"Id":391529,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08080325100"},{"Id":391530,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036380","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/4\"","NDC":"08080325114"},{"Id":391531,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 27GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036390","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 27 X 1-1/4\"","NDC":"08080327114"},{"Id":391532,"FormularyType":"OHP","DrugName":"CURITY GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080338100"},{"Id":391533,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441203"},{"Id":391534,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441204"},{"Id":391535,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441205"},{"Id":391536,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441211"},{"Id":391537,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441218"},{"Id":391538,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441400"},{"Id":391539,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441403"},{"Id":391540,"FormularyType":"OHP","DrugName":"DERMACEA IV PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080441408"},{"Id":391541,"FormularyType":"OHP","DrugName":"DERMACEA PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080442308"},{"Id":391542,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 35ML/REG","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08080500555"},{"Id":391543,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 35ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08080500777"},{"Id":391544,"FormularyType":"OHP","DrugName":"MONOJECT S/P MIS 35/CATH","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08080500888"},{"Id":391545,"FormularyType":"OHP","DrugName":"PHARM SYRNG MIS TRAY 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08080501459"},{"Id":391546,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08080501640"},{"Id":391547,"FormularyType":"OHP","DrugName":"WEBCOL PREP PAD LARGE","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08080503300"},{"Id":391548,"FormularyType":"OHP","DrugName":"WEBCOL PREP PAD LARGE","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08080511000"},{"Id":391549,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS CANNULA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08080541034"},{"Id":391550,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS CANNULA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08080541067"},{"Id":391551,"FormularyType":"OHP","DrugName":"KENDALL FOAM PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080555220"},{"Id":391552,"FormularyType":"OHP","DrugName":"KENDALL FOAM PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080555221"},{"Id":391553,"FormularyType":"OHP","DrugName":"CURITY PREP PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08080575000"},{"Id":391554,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS CATH TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08080600444"},{"Id":391555,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08080600555"},{"Id":391556,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08080600777"},{"Id":391557,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066325","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 20 X 1-1/2\"","NDC":"08080620112"},{"Id":391558,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066330","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 21 X 1\"","NDC":"08080621100"},{"Id":391559,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066340","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 21 X 1-1/2\"","NDC":"08080621112"},{"Id":391560,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066360","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 22 X 1-1/2\"","NDC":"08080622112"},{"Id":391561,"FormularyType":"OHP","DrugName":"DERMACEA I.V PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080624100"},{"Id":391562,"FormularyType":"OHP","DrugName":"WEBCOL PREP PAD MEDIUM","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08080681800"},{"Id":391563,"FormularyType":"OHP","DrugName":"I.V. SPONGES PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080708700"},{"Id":391564,"FormularyType":"OHP","DrugName":"CURITY SPONG PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080804200"},{"Id":391565,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030056320","GenericName":"INSULIN SYRINGE (DISP) U-100 1 ML","NDC":"08080810055"},{"Id":391566,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08080812701"},{"Id":391567,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08080812801"},{"Id":391568,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08080818100"},{"Id":391569,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08080818112"},{"Id":391570,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08080818113"},{"Id":391571,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08080819100"},{"Id":391572,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08080819112"},{"Id":391573,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08080820100"},{"Id":391574,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08080820112"},{"Id":391575,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08080821100"},{"Id":391576,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08080821112"},{"Id":391577,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08080822100"},{"Id":391578,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08080822112"},{"Id":391579,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08080823100"},{"Id":391580,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08080825058"},{"Id":391581,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08080825100"},{"Id":391582,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08080825112"},{"Id":391583,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266330","GenericName":"NEEDLE (DISP) 26 X 1-1/2\"","NDC":"08080826112"},{"Id":391584,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08080827012"},{"Id":391585,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276330","GenericName":"NEEDLE (DISP) 27 X 1-1/2\"","NDC":"08080827112"},{"Id":391586,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 30GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306315","GenericName":"NEEDLE (DISP) 30 X 3/4\"","NDC":"08080830340"},{"Id":391587,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08080850010"},{"Id":391588,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08080850015"},{"Id":391589,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08080850110"},{"Id":391590,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08080850115"},{"Id":391591,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 21GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216312","GenericName":"NEEDLE (DISP) 21 X 5/8\"","NDC":"08080850158"},{"Id":391592,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08080850210"},{"Id":391593,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08080850215"},{"Id":391594,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08080850310"},{"Id":391595,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 23GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236312","GenericName":"NEEDLE (DISP) 23 X 5/8\"","NDC":"08080850358"},{"Id":391596,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08080850510"},{"Id":391597,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08080850558"},{"Id":391598,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08080850810"},{"Id":391599,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08080850815"},{"Id":391600,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08080850910"},{"Id":391601,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08080850915"},{"Id":391602,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08080852801"},{"Id":391603,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066305","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 18 X 1\"","NDC":"08080866810"},{"Id":391604,"FormularyType":"OHP","DrugName":"CURITY SPONG PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080902200"},{"Id":391605,"FormularyType":"OHP","DrugName":"CURITY SPONG PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08080913200"},{"Id":391606,"FormularyType":"OHP","DrugName":"AVEENO CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"08137003658"},{"Id":391607,"FormularyType":"OHP","DrugName":"EASY RELEASE PAD NONSTICK","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"08137004731"},{"Id":391608,"FormularyType":"OHP","DrugName":"J & J ADHES PAD LARGE","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"08137004768"},{"Id":391609,"FormularyType":"OHP","DrugName":"J&J GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08137007612"},{"Id":391610,"FormularyType":"OHP","DrugName":"BAND-AID PAD ADHESIVE","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"08137016628"},{"Id":391611,"FormularyType":"OHP","DrugName":"BAND-AID PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08137116123"},{"Id":391612,"FormularyType":"OHP","DrugName":"BAND-AID PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08137116124"},{"Id":391613,"FormularyType":"OHP","DrugName":"BAND-AID PAD 3\"X4\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"08137116143"},{"Id":391614,"FormularyType":"OHP","DrugName":"MIRASORB MIS 2\" X 2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08137607612"},{"Id":391615,"FormularyType":"OHP","DrugName":"MIRASORB MIS 2\" X 2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08137607613"},{"Id":391616,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214029724"},{"Id":391617,"FormularyType":"OHP","DrugName":"INCONTROL MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214029727"},{"Id":391618,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214029739"},{"Id":391619,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214029740"},{"Id":391620,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214030724"},{"Id":391621,"FormularyType":"OHP","DrugName":"IN CONTROL MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214030727"},{"Id":391622,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214030739"},{"Id":391623,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214030740"},{"Id":391624,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214040727"},{"Id":391625,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214040734"},{"Id":391626,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214050716"},{"Id":391627,"FormularyType":"OHP","DrugName":"IN CONTROL MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214050727"},{"Id":391628,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214050734"},{"Id":391629,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214053080"},{"Id":391630,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214054080"},{"Id":391631,"FormularyType":"OHP","DrugName":"IN CONTROL MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214055027"},{"Id":391632,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214055080"},{"Id":391633,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214056080"},{"Id":391634,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214056717"},{"Id":391635,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214057716"},{"Id":391636,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214057717"},{"Id":391637,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214058716"},{"Id":391638,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214058717"},{"Id":391639,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214059080"},{"Id":391640,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214082921"},{"Id":391641,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214083021"},{"Id":391642,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214083027"},{"Id":391643,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214083054"},{"Id":391644,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214084021"},{"Id":391645,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214084027"},{"Id":391646,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214084054"},{"Id":391647,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214084739"},{"Id":391648,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214085021"},{"Id":391649,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214085029"},{"Id":391650,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214085054"},{"Id":391651,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214086021"},{"Id":391652,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214086027"},{"Id":391653,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214089021"},{"Id":391654,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214089027"},{"Id":391655,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214089054"},{"Id":391656,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214090724"},{"Id":391657,"FormularyType":"OHP","DrugName":"IN CONTROL MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214090727"},{"Id":391658,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214090739"},{"Id":391659,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214114027"},{"Id":391660,"FormularyType":"OHP","DrugName":"IN CONTROL MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214115027"},{"Id":391661,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214183027"},{"Id":391662,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214184027"},{"Id":391663,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214185027"},{"Id":391664,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214189027"},{"Id":391665,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214352719"},{"Id":391666,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214352901"},{"Id":391667,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214352933"},{"Id":391668,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214353001"},{"Id":391669,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214353033"},{"Id":391670,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214354033"},{"Id":391671,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214359001"},{"Id":391672,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08214359033"},{"Id":391673,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214383034"},{"Id":391674,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08214384034"},{"Id":391675,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08214385034"},{"Id":391676,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08214998901"},{"Id":391677,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08214998921"},{"Id":391678,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222025432"},{"Id":391679,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222025630"},{"Id":391680,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222025838"},{"Id":391681,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08222032195"},{"Id":391682,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08222032591"},{"Id":391683,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222035431"},{"Id":391684,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222035530"},{"Id":391685,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222035639"},{"Id":391686,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222035837"},{"Id":391687,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222045430"},{"Id":391688,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222045539"},{"Id":391689,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222045621"},{"Id":391690,"FormularyType":"OHP","DrugName":"1 ML SYRINGE MIS 22X1-1/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016335","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 22 G X 1-1/2\"","NDC":"08222051257"},{"Id":391691,"FormularyType":"OHP","DrugName":"3 ML SYRINGE MIS 22X1-1/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08222053251"},{"Id":391692,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222055439"},{"Id":391693,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222055538"},{"Id":391694,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222055620"},{"Id":391695,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222055835"},{"Id":391696,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222065439"},{"Id":391697,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222065620"},{"Id":391698,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08222073150"},{"Id":391699,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08222073358"},{"Id":391700,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08222073556"},{"Id":391701,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08222074195"},{"Id":391702,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08222074393"},{"Id":391703,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08222074591"},{"Id":391704,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08222082183"},{"Id":391705,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08222082589"},{"Id":391706,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222085436"},{"Id":391707,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222085634"},{"Id":391708,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222085832"},{"Id":391709,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08222092199"},{"Id":391710,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08222092397"},{"Id":391711,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08222092595"},{"Id":391712,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08222093158"},{"Id":391713,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08222093196"},{"Id":391714,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08222093356"},{"Id":391715,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08222093394"},{"Id":391716,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08222093554"},{"Id":391717,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08222093592"},{"Id":391718,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08222094193"},{"Id":391719,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08222094391"},{"Id":391720,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08222094599"},{"Id":391721,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08222095121"},{"Id":391722,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222095435"},{"Id":391723,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222095459"},{"Id":391724,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222095534"},{"Id":391725,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222095626"},{"Id":391726,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222095633"},{"Id":391727,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222095657"},{"Id":391728,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222095831"},{"Id":391729,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222095855"},{"Id":391730,"FormularyType":"OHP","DrugName":"INS SYR 1ML MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08222123152"},{"Id":391731,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08222123350"},{"Id":391732,"FormularyType":"OHP","DrugName":"INS SY 1/2ML MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08222123558"},{"Id":391733,"FormularyType":"OHP","DrugName":"INS SYR 1ML MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08222124197"},{"Id":391734,"FormularyType":"OHP","DrugName":"INS SY 0.3ML MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08222124395"},{"Id":391735,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08222124593"},{"Id":391736,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08222125125"},{"Id":391737,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222125439"},{"Id":391738,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222125538"},{"Id":391739,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222125620"},{"Id":391740,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222125835"},{"Id":391741,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222135438"},{"Id":391742,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222135537"},{"Id":391743,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222135629"},{"Id":391744,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222135834"},{"Id":391745,"FormularyType":"OHP","DrugName":"ULTICARE MIC MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222142387"},{"Id":391746,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222142394"},{"Id":391747,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222142400"},{"Id":391748,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222143896"},{"Id":391749,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08222172396"},{"Id":391750,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08222173195"},{"Id":391751,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08222173393"},{"Id":391752,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08222173591"},{"Id":391753,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08222174192"},{"Id":391754,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08222174390"},{"Id":391755,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08222174598"},{"Id":391756,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08222182180"},{"Id":391757,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08222182586"},{"Id":391758,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08222192196"},{"Id":391759,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08222192592"},{"Id":391760,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08222193155"},{"Id":391761,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08222193353"},{"Id":391762,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08222193551"},{"Id":391763,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706334","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08222251107"},{"Id":391764,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08222251589"},{"Id":391765,"FormularyType":"OHP","DrugName":"ULTICARE PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08222440006"},{"Id":391766,"FormularyType":"OHP","DrugName":"ULTICARE PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08222440013"},{"Id":391767,"FormularyType":"OHP","DrugName":"ULTICARE MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222610058"},{"Id":391768,"FormularyType":"OHP","DrugName":"ULTICARE MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222610089"},{"Id":391769,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016388","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 5/8\"","NDC":"08222630001"},{"Id":391770,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016387","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08222630018"},{"Id":391771,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016391","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08222630025"},{"Id":391772,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08222630032"},{"Id":391773,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08222630049"},{"Id":391774,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08222630056"},{"Id":391775,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08222630063"},{"Id":391776,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08222630070"},{"Id":391777,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08222630087"},{"Id":391778,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08222630148"},{"Id":391779,"FormularyType":"OHP","DrugName":"INCONTROL MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222678006"},{"Id":391780,"FormularyType":"OHP","DrugName":"INCONTROL MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222678044"},{"Id":391781,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222710000"},{"Id":391782,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222710017"},{"Id":391783,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222710024"},{"Id":391784,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222710031"},{"Id":391785,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222710048"},{"Id":391786,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222710055"},{"Id":391787,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08222710062"},{"Id":391788,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222710079"},{"Id":391789,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222710086"},{"Id":391790,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222710093"},{"Id":391791,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222710130"},{"Id":391792,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222710147"},{"Id":391793,"FormularyType":"OHP","DrugName":"INCONTROL MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222719372"},{"Id":391794,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222720031"},{"Id":391795,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222720055"},{"Id":391796,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08222720078"},{"Id":391797,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222720085"},{"Id":391798,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08222720092"},{"Id":391799,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08222720130"},{"Id":391800,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08222720147"},{"Id":391801,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08222910004"},{"Id":391802,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08222910011"},{"Id":391803,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08222910028"},{"Id":391804,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08222910035"},{"Id":391805,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08222910042"},{"Id":391806,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08222910059"},{"Id":391807,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"08222910066"},{"Id":391808,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"08222910073"},{"Id":391809,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906336","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X 1/4\" (6 MM)","NDC":"08222910080"},{"Id":391810,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906337","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 1/4\" (6 MM)","NDC":"08222910097"},{"Id":391811,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"08222910103"},{"Id":391812,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"08222910110"},{"Id":391813,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906336","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X 1/4\" (6 MM)","NDC":"08222910127"},{"Id":391814,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906337","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 1/4\" (6 MM)","NDC":"08222910134"},{"Id":391815,"FormularyType":"OHP","DrugName":"PRECISIONGLI MIS 27GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276330","GenericName":"NEEDLE (DISP) 27 X 1-1/2\"","NDC":"08290301629"},{"Id":391816,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08290302830"},{"Id":391817,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS SLIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08290302831"},{"Id":391818,"FormularyType":"OHP","DrugName":"30ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006330","GenericName":"SYRINGE (DISPOSABLE) 30 ML","NDC":"08290302832"},{"Id":391819,"FormularyType":"OHP","DrugName":"BD LUER-LOK MIS SYR 10ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290302995"},{"Id":391820,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS SLIP TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290303134"},{"Id":391821,"FormularyType":"OHP","DrugName":"BD PRECISION MIS 27GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276303","GenericName":"NEEDLE (DISP) 27 X 3/8\"","NDC":"08290303302"},{"Id":391822,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"08290303306"},{"Id":391823,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 27GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706348","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 3/8\"","NDC":"08290303327"},{"Id":391824,"FormularyType":"OHP","DrugName":"BD TB 1ML MIS 27GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706348","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 3/8\"","NDC":"08290303344"},{"Id":391825,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS CANNULA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290303348"},{"Id":391826,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS CANNULA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290303393"},{"Id":391827,"FormularyType":"OHP","DrugName":"BD SAFETY MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"08290304387"},{"Id":391828,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036310","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1-1/2\"","NDC":"08290305060"},{"Id":391829,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306305","GenericName":"NEEDLE (DISP) 30 X 1/2\"","NDC":"08290305106"},{"Id":391830,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08290305109"},{"Id":391831,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 26GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266305","GenericName":"NEEDLE (DISP) 26 X 1/2\"","NDC":"08290305111"},{"Id":391832,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08290305122"},{"Id":391833,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 25GX7/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256317","GenericName":"NEEDLE (DISP) 25 X 7/8\"","NDC":"08290305124"},{"Id":391834,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08290305125"},{"Id":391835,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08290305127"},{"Id":391836,"FormularyType":"OHP","DrugName":"BD NEEDLE MIS 30G X 1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306320","GenericName":"NEEDLE (DISP) 30 X 1\"","NDC":"08290305128"},{"Id":391837,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 21GX2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216335","GenericName":"NEEDLE (DISP) 21 X 2\"","NDC":"08290305129"},{"Id":391838,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 23GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236315","GenericName":"NEEDLE (DISP) 23 X 3/4\"","NDC":"08290305143"},{"Id":391839,"FormularyType":"OHP","DrugName":"BD NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08290305145"},{"Id":391840,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08290305155"},{"Id":391841,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08290305156"},{"Id":391842,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08290305159"},{"Id":391843,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08290305165"},{"Id":391844,"FormularyType":"OHP","DrugName":"YALE NEEDLES MIS 21GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216325","GenericName":"NEEDLE (DISP) 21 X 1-1/4\"","NDC":"08290305166"},{"Id":391845,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08290305167"},{"Id":391846,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08290305175"},{"Id":391847,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08290305176"},{"Id":391848,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08290305178"},{"Id":391849,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08290305179"},{"Id":391850,"FormularyType":"OHP","DrugName":"BD BLUNT FIL MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08290305181"},{"Id":391851,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305185"},{"Id":391852,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08290305186"},{"Id":391853,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08290305187"},{"Id":391854,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08290305188"},{"Id":391855,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08290305189"},{"Id":391856,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08290305193"},{"Id":391857,"FormularyType":"OHP","DrugName":"BD PRECISION MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"08290305194"},{"Id":391858,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08290305195"},{"Id":391859,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305196"},{"Id":391860,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 16GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166320","GenericName":"NEEDLE (DISP) 16 X 1\"","NDC":"08290305197"},{"Id":391861,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 16GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166330","GenericName":"NEEDLE (DISP) 16 X 1-1/2\"","NDC":"08290305198"},{"Id":391862,"FormularyType":"OHP","DrugName":"BD HYPO NEED MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305199"},{"Id":391863,"FormularyType":"OHP","DrugName":"BD BLNT FILL MIS 18GX1.5","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305211"},{"Id":391864,"FormularyType":"OHP","DrugName":"VENT NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08290305214"},{"Id":391865,"FormularyType":"OHP","DrugName":"ADMIX NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305215"},{"Id":391866,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08290305269"},{"Id":391867,"FormularyType":"OHP","DrugName":"BD INTEGRA MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08290305270"},{"Id":391868,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08290305271"},{"Id":391869,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08290305272"},{"Id":391870,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08290305273"},{"Id":391871,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08290305274"},{"Id":391872,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08290305312"},{"Id":391873,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS ECC TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290305482"},{"Id":391874,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08290305500"},{"Id":391875,"FormularyType":"OHP","DrugName":"ALLERGY SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706310","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1/2 ML 27 X 1/2\"","NDC":"08290305535"},{"Id":391876,"FormularyType":"OHP","DrugName":"ALLERGY SYRG MIS 27GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706315","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1/2 ML 27 X 3/8\"","NDC":"08290305536"},{"Id":391877,"FormularyType":"OHP","DrugName":"ALLERGIST KIT 27GX1/2\"","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706460","GenericName":"ALLERGY TRAY KIT 1 ML 27 X 1/2\"","NDC":"08290305540"},{"Id":391878,"FormularyType":"OHP","DrugName":"ALLERGY SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706348","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 3/8\"","NDC":"08290305541"},{"Id":391879,"FormularyType":"OHP","DrugName":"ALLERGY SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706348","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 3/8\"","NDC":"08290305542"},{"Id":391880,"FormularyType":"OHP","DrugName":"BD 20ML SYRG MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08290305617"},{"Id":391881,"FormularyType":"OHP","DrugName":"30ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006330","GenericName":"SYRINGE (DISPOSABLE) 30 ML","NDC":"08290305618"},{"Id":391882,"FormularyType":"OHP","DrugName":"1/2ML TB SYR MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706310","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1/2 ML 27 X 1/2\"","NDC":"08290305620"},{"Id":391883,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305712"},{"Id":391884,"FormularyType":"OHP","DrugName":"BD NEEDLE MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306305","GenericName":"NEEDLE (DISP) 30 X 1/2\"","NDC":"08290305757"},{"Id":391885,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08290305758"},{"Id":391886,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08290305759"},{"Id":391887,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08290305761"},{"Id":391888,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08290305762"},{"Id":391889,"FormularyType":"OHP","DrugName":"ECLIPSE NDL MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08290305764"},{"Id":391890,"FormularyType":"OHP","DrugName":"ECLIPSE NDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08290305765"},{"Id":391891,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305766"},{"Id":391892,"FormularyType":"OHP","DrugName":"ECLIPSE NDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08290305767"},{"Id":391893,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016395","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 30 X 1/2\"","NDC":"08290305778"},{"Id":391894,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08290305779"},{"Id":391895,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08290305780"},{"Id":391896,"FormularyType":"OHP","DrugName":"SYRG/NDL 3ML MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08290305781"},{"Id":391897,"FormularyType":"OHP","DrugName":"SYRG/NDL 3ML MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08290305782"},{"Id":391898,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08290305787"},{"Id":391899,"FormularyType":"OHP","DrugName":"SYRG/NDL 3ML MIS 22G X 1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08290305788"},{"Id":391900,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016387","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08290305789"},{"Id":391901,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08290305826"},{"Id":391902,"FormularyType":"OHP","DrugName":"BD ECLIPSE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08290305829"},{"Id":391903,"FormularyType":"OHP","DrugName":"ECLIPSE NDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08290305838"},{"Id":391904,"FormularyType":"OHP","DrugName":"SAFETY NEEDL MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08290305900"},{"Id":391905,"FormularyType":"OHP","DrugName":"BD NEEDLES MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08290305901"},{"Id":391906,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08290305902"},{"Id":391907,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08290305903"},{"Id":391908,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08290305904"},{"Id":391909,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08290305905"},{"Id":391910,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08290305906"},{"Id":391911,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"08290305907"},{"Id":391912,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08290305909"},{"Id":391913,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08290305915"},{"Id":391914,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08290305916"},{"Id":391915,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08290305917"},{"Id":391916,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08290305918"},{"Id":391917,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 27GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276310","GenericName":"NEEDLE (DISP) 27 X 5/8\"","NDC":"08290305921"},{"Id":391918,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08290305924"},{"Id":391919,"FormularyType":"OHP","DrugName":"SAFETYGLIDE MIS 27GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016388","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 5/8\"","NDC":"08290305927"},{"Id":391920,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08290305930"},{"Id":391921,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08290305932"},{"Id":391922,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08290305934"},{"Id":391923,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08290305935"},{"Id":391924,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290305937"},{"Id":391925,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08290305945"},{"Id":391926,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706340","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"08290305946"},{"Id":391927,"FormularyType":"OHP","DrugName":"1ML ALLR SYR MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08290305950"},{"Id":391928,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08290309310"},{"Id":391929,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08290309570"},{"Id":391930,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08290309571"},{"Id":391931,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08290309572"},{"Id":391932,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08290309574"},{"Id":391933,"FormularyType":"OHP","DrugName":"BD PLASTIPAK MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08290309575"},{"Id":391934,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08290309577"},{"Id":391935,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08290309578"},{"Id":391936,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036310","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1-1/2\"","NDC":"08290309580"},{"Id":391937,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08290309581"},{"Id":391938,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"08290309582"},{"Id":391939,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 26GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036388","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 26 X 5/8\"","NDC":"08290309587"},{"Id":391940,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08290309588"},{"Id":391941,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"08290309589"},{"Id":391942,"FormularyType":"OHP","DrugName":"SLIP TIP 1ML MIS 26GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016370","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 26 X 5/8\"","NDC":"08290309597"},{"Id":391943,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08290309598"},{"Id":391944,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08290309599"},{"Id":391945,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290309604"},{"Id":391946,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290309605"},{"Id":391947,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08290309623"},{"Id":391948,"FormularyType":"OHP","DrugName":"TB SYRNG 1ML MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706323","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 21 X 1\"","NDC":"08290309624"},{"Id":391949,"FormularyType":"OHP","DrugName":"1ML SLIP TIP MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706340","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"08290309625"},{"Id":391950,"FormularyType":"OHP","DrugName":"1ML SLIP TIP MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08290309626"},{"Id":391951,"FormularyType":"OHP","DrugName":"SYRINGE LUER MIS -LOK 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08290309628"},{"Id":391952,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030056320","GenericName":"INSULIN SYRINGE (DISP) U-100 1 ML","NDC":"08290309629"},{"Id":391953,"FormularyType":"OHP","DrugName":"5ML LL SYRNG MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056350","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1\"","NDC":"08290309630"},{"Id":391954,"FormularyType":"OHP","DrugName":"5ML LL SYRNG MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"08290309631"},{"Id":391955,"FormularyType":"OHP","DrugName":"5ML LL SYRNG MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056330","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1\"","NDC":"08290309632"},{"Id":391956,"FormularyType":"OHP","DrugName":"5ML LL SYRNG MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"08290309633"},{"Id":391957,"FormularyType":"OHP","DrugName":"5ML LL SYRNG MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056320","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1\"","NDC":"08290309634"},{"Id":391958,"FormularyType":"OHP","DrugName":"5ML LL SYRNG MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056325","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1-1/2\"","NDC":"08290309635"},{"Id":391959,"FormularyType":"OHP","DrugName":"LUER-LOK SYR MIS 1ML/20G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016325","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 20 X 1\"","NDC":"08290309637"},{"Id":391960,"FormularyType":"OHP","DrugName":"10ML LL SYRN MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106350","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 22 X 1\"","NDC":"08290309640"},{"Id":391961,"FormularyType":"OHP","DrugName":"10ML LL SYRN MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106330","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1\"","NDC":"08290309642"},{"Id":391962,"FormularyType":"OHP","DrugName":"10ML LL SYRN MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106340","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1-1/2\"","NDC":"08290309643"},{"Id":391963,"FormularyType":"OHP","DrugName":"10ML LL SYRN MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106320","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 20 X 1\"","NDC":"08290309644"},{"Id":391964,"FormularyType":"OHP","DrugName":"10ML LL SYRN MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106325","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 20 X 1-1/2\"","NDC":"08290309645"},{"Id":391965,"FormularyType":"OHP","DrugName":"LUER-LOK MIS SYRG 5ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"08290309646"},{"Id":391966,"FormularyType":"OHP","DrugName":"SYRINGE 5ML MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"08290309647"},{"Id":391967,"FormularyType":"OHP","DrugName":"BD SYR 50ML MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006350","GenericName":"SYRINGE (DISPOSABLE) 50 ML","NDC":"08290309653"},{"Id":391968,"FormularyType":"OHP","DrugName":"BD SYR 50ML MIS SLIP TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006350","GenericName":"SYRINGE (DISPOSABLE) 50 ML","NDC":"08290309654"},{"Id":391969,"FormularyType":"OHP","DrugName":"SLIP TIP 3ML MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08290309656"},{"Id":391970,"FormularyType":"OHP","DrugName":"BD PLASTIPAK MIS 3ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08290309657"},{"Id":391971,"FormularyType":"OHP","DrugName":"SLIP TIP 1ML MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08290309659"},{"Id":391972,"FormularyType":"OHP","DrugName":"BD 50ML SYRG MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006350","GenericName":"SYRINGE (DISPOSABLE) 50 ML","NDC":"08290309680"},{"Id":391973,"FormularyType":"OHP","DrugName":"10ML LL SYRG MIS CONTROL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08290309695"},{"Id":391974,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS SLIP TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08290309701"},{"Id":391975,"FormularyType":"OHP","DrugName":"LUER-LOCK MIS SYRG 3ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08290309702"},{"Id":391976,"FormularyType":"OHP","DrugName":"BD 5ML SYRG MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"08290309703"},{"Id":391977,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08290320109"},{"Id":391978,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08290320119"},{"Id":391979,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08290320122"},{"Id":391980,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08290320550"},{"Id":391981,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08290320574"},{"Id":391982,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08290320749"},{"Id":391983,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08290320880"},{"Id":391984,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08290320881"},{"Id":391985,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08290320882"},{"Id":391986,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08290320883"},{"Id":391987,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08290324702"},{"Id":391988,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08290324703"},{"Id":391989,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08290324704"},{"Id":391990,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08290324705"},{"Id":391991,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08290324906"},{"Id":391992,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08290324907"},{"Id":391993,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08290324908"},{"Id":391994,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08290324909"},{"Id":391995,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08290324910"},{"Id":391996,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08290324911"},{"Id":391997,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08290324912"},{"Id":391998,"FormularyType":"OHP","DrugName":"INS SYR U500 MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030956330","GenericName":"INSULIN SYRINGE/NEEDLE U-500 0.5 ML 31G X 6MM (15/64\")","NDC":"08290326730"},{"Id":391999,"FormularyType":"OHP","DrugName":"BD SWAB REG PAD SNGL USE","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08290326895"},{"Id":392000,"FormularyType":"OHP","DrugName":"BD PEN NEEDL MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08290328203"},{"Id":392001,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08290328278"},{"Id":392002,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08290328279"},{"Id":392003,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08290328280"},{"Id":392004,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08290328289"},{"Id":392005,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08290328290"},{"Id":392006,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290328291"},{"Id":392007,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08290328411"},{"Id":392008,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08290328418"},{"Id":392009,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08290328431"},{"Id":392010,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290328438"},{"Id":392011,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290328440"},{"Id":392012,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08290328446"},{"Id":392013,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08290328447"},{"Id":392014,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08290328449"},{"Id":392015,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08290328466"},{"Id":392016,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08290328468"},{"Id":392017,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08290329410"},{"Id":392018,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906360","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 5/8\"","NDC":"08290329412"},{"Id":392019,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08290329420"},{"Id":392020,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08290329424"},{"Id":392021,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08290329431"},{"Id":392022,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08290329461"},{"Id":392023,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08290329465"},{"Id":392024,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08290329466"},{"Id":392025,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 2/27.5G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906390","GenericName":"INSULIN SYRINGE/NEEDLE U-100 2 ML 27.5 X 5/8\"","NDC":"08290329485"},{"Id":392026,"FormularyType":"OHP","DrugName":"AUTOSHIELD MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08290329515"},{"Id":392027,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08290490901"},{"Id":392028,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08290491001"},{"Id":392029,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08290491101"},{"Id":392030,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08290491201"},{"Id":392031,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08290593001"},{"Id":392032,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08290593201"},{"Id":392033,"FormularyType":"OHP","DrugName":"BD GLUCOSE CHW 5GM","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000520","GenericName":"GLUCOSE CHEW TAB 5 GM","NDC":"08290823000"},{"Id":392034,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08290841002"},{"Id":392035,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08290841101"},{"Id":392036,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08290841103"},{"Id":392037,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906360","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 5/8\"","NDC":"08290841201"},{"Id":392038,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906360","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 5/8\"","NDC":"08290841203"},{"Id":392039,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08290841801"},{"Id":392040,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08290843101"},{"Id":392041,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08290843103"},{"Id":392042,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290843801"},{"Id":392043,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290843803"},{"Id":392044,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08290844001"},{"Id":392045,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08290846601"},{"Id":392046,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08290846603"},{"Id":392047,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08290846801"},{"Id":392048,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08317232129"},{"Id":392049,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08317234132"},{"Id":392050,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08317234232"},{"Id":392051,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08317235131"},{"Id":392052,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08317236132"},{"Id":392053,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08317238131"},{"Id":392054,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08317260305"},{"Id":392055,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08317260311"},{"Id":392056,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08317260312"},{"Id":392057,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08317260313"},{"Id":392058,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08317260314"},{"Id":392059,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08317260315"},{"Id":392060,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08317260316"},{"Id":392061,"FormularyType":"OHP","DrugName":"ASSURE ID MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08317276530"},{"Id":392062,"FormularyType":"OHP","DrugName":"ASSURE ID MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08317277531"},{"Id":392063,"FormularyType":"OHP","DrugName":"ASSURE ID MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08317278130"},{"Id":392064,"FormularyType":"OHP","DrugName":"ULTILET PEN MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08326290012"},{"Id":392065,"FormularyType":"OHP","DrugName":"ULTILET PEN MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"08326290212"},{"Id":392066,"FormularyType":"OHP","DrugName":"ULTILET PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08326310005"},{"Id":392067,"FormularyType":"OHP","DrugName":"ULTILET PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08326310008"},{"Id":392068,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08326310905"},{"Id":392069,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08326310908"},{"Id":392070,"FormularyType":"OHP","DrugName":"ULTILET PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08326320004"},{"Id":392071,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08326320904"},{"Id":392072,"FormularyType":"OHP","DrugName":"INTELISWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"08337000158"},{"Id":392073,"FormularyType":"OHP","DrugName":"PERSONAL BES MIS FULL RNG","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08373075500"},{"Id":392074,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIAMOND","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"08373747800"},{"Id":392075,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIA SM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"08373982300"},{"Id":392076,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIA MD","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"08373982600"},{"Id":392077,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIA LG","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"08373982700"},{"Id":392078,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIAMOND","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"08373983000"},{"Id":392079,"FormularyType":"OHP","DrugName":"KIMONO SPEC MIS","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"08388911012"},{"Id":392080,"FormularyType":"OHP","DrugName":"KIMONO COLOR MIS","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"08388913012"},{"Id":392081,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08421010131"},{"Id":392082,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08421010151"},{"Id":392083,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08421010301"},{"Id":392084,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08421010311"},{"Id":392085,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"08421010321"},{"Id":392086,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08421010331"},{"Id":392087,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08421010341"},{"Id":392088,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08421010351"},{"Id":392089,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08421010361"},{"Id":392090,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08421010371"},{"Id":392091,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"08421010381"},{"Id":392092,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08421010391"},{"Id":392093,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"08421010541"},{"Id":392094,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056330","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1\"","NDC":"08421010551"},{"Id":392095,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"08421010561"},{"Id":392096,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106340","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1-1/2\"","NDC":"08421011061"},{"Id":392097,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"08421013011"},{"Id":392098,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08421015221"},{"Id":392099,"FormularyType":"OHP","DrugName":"CRONO SYR MIS 10ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106314","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 19G X 1-1/2\"","NDC":"08423200110"},{"Id":392100,"FormularyType":"OHP","DrugName":"CRONO SYR MIS 20ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040206320","GenericName":"SYRINGE/NEEDLE (DISP) 20 ML 19G X 1-1/2\"","NDC":"08423200220"},{"Id":392101,"FormularyType":"OHP","DrugName":"PIKO 1 MIS ELECTRON","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08439345010"},{"Id":392102,"FormularyType":"OHP","DrugName":"PIKO 1 MIS ELECTRON","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08439345011"},{"Id":392103,"FormularyType":"OHP","DrugName":"PIKO 1 MIS ELECTRON","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08439345012"},{"Id":392104,"FormularyType":"OHP","DrugName":"PIKO 1 MIS ELECTRON","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08439345013"},{"Id":392105,"FormularyType":"OHP","DrugName":"POCKET PEAK MIS METER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08439600101"},{"Id":392106,"FormularyType":"OHP","DrugName":"POCKET PEAK MIS METER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08439600112"},{"Id":392107,"FormularyType":"OHP","DrugName":"PANDA MASK MIS PEDIATRI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640101"},{"Id":392108,"FormularyType":"OHP","DrugName":"PANDA MASK MIS SMALL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640102"},{"Id":392109,"FormularyType":"OHP","DrugName":"PANDA MASK MIS MEDIUM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640103"},{"Id":392110,"FormularyType":"OHP","DrugName":"PANDA MASK MIS LARGE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640105"},{"Id":392111,"FormularyType":"OHP","DrugName":"PANDA MASK MIS PEDIATRI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640111"},{"Id":392112,"FormularyType":"OHP","DrugName":"PANDA MASK MIS SMALL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640112"},{"Id":392113,"FormularyType":"OHP","DrugName":"PANDA MASK MIS MEDIUM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640113"},{"Id":392114,"FormularyType":"OHP","DrugName":"PANDA MASK MIS LARGE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"08439640115"},{"Id":392115,"FormularyType":"OHP","DrugName":"FEMCAP MIS 22MM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401810006222","GenericName":"CERVICAL CAP 22 MM","NDC":"08454000122"},{"Id":392116,"FormularyType":"OHP","DrugName":"FEMCAP MIS 26MM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401810006226","GenericName":"CERVICAL CAP 26 MM","NDC":"08454000226"},{"Id":392117,"FormularyType":"OHP","DrugName":"FEMCAP MIS 30MM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401810006230","GenericName":"CERVICAL CAP 30 MM","NDC":"08454000330"},{"Id":392118,"FormularyType":"OHP","DrugName":"MINI WRIGHT MIS PFM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08462103104"},{"Id":392119,"FormularyType":"OHP","DrugName":"MINI WRIGHT MIS PFM LOW","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08462104001"},{"Id":392120,"FormularyType":"OHP","DrugName":"AIRZONE PEAK MIS FLOW MTR","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"08462130045"},{"Id":392121,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470054001"},{"Id":392122,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470054041"},{"Id":392123,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08470112901"},{"Id":392124,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470113001"},{"Id":392125,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470114001"},{"Id":392126,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470115001"},{"Id":392127,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470119001"},{"Id":392128,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08470182901"},{"Id":392129,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470183001"},{"Id":392130,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470184001"},{"Id":392131,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470185001"},{"Id":392132,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470189001"},{"Id":392133,"FormularyType":"OHP","DrugName":"PENTIPS MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08470342901"},{"Id":392134,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470343001"},{"Id":392135,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470344001"},{"Id":392136,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470345001"},{"Id":392137,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470349001"},{"Id":392138,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470349501"},{"Id":392139,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08470352901"},{"Id":392140,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470353001"},{"Id":392141,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470354001"},{"Id":392142,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470355001"},{"Id":392143,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470355501"},{"Id":392144,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470356001"},{"Id":392145,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470359001"},{"Id":392146,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470359501"},{"Id":392147,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08470382901"},{"Id":392148,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470383001"},{"Id":392149,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470384001"},{"Id":392150,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470385001"},{"Id":392151,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470385501"},{"Id":392152,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470386001"},{"Id":392153,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470389001"},{"Id":392154,"FormularyType":"OHP","DrugName":"UNIFINE ULTR MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470413001"},{"Id":392155,"FormularyType":"OHP","DrugName":"UNIFINE ULTR MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470414001"},{"Id":392156,"FormularyType":"OHP","DrugName":"UNIFINE ULTR MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470415001"},{"Id":392157,"FormularyType":"OHP","DrugName":"UNIFINE ULTR MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470419001"},{"Id":392158,"FormularyType":"OHP","DrugName":"UNIFINE PROT MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470783501"},{"Id":392159,"FormularyType":"OHP","DrugName":"UNIFINE PROT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470784501"},{"Id":392160,"FormularyType":"OHP","DrugName":"UNIFINE PROT MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470785501"},{"Id":392161,"FormularyType":"OHP","DrugName":"UNIFINE SAFE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470793001"},{"Id":392162,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08470793501"},{"Id":392163,"FormularyType":"OHP","DrugName":"UNIFINE SAFE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08470794001"},{"Id":392164,"FormularyType":"OHP","DrugName":"UNIFINE SAFE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470795001"},{"Id":392165,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08470795501"},{"Id":392166,"FormularyType":"OHP","DrugName":"UNIFINE SAFE MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08470799001"},{"Id":392167,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08484990430"},{"Id":392168,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08484990432"},{"Id":392169,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08484990435"},{"Id":392170,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08484990437"},{"Id":392171,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08484990438"},{"Id":392172,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08489600110"},{"Id":392173,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08489600210"},{"Id":392174,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08489600310"},{"Id":392175,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08489600410"},{"Id":392176,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08489600510"},{"Id":392177,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08489600610"},{"Id":392178,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08489600710"},{"Id":392179,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08489600810"},{"Id":392180,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08489600910"},{"Id":392181,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08489601110"},{"Id":392182,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08489601210"},{"Id":392183,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08489601310"},{"Id":392184,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906361","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 15/64\"","NDC":"08489601410"},{"Id":392185,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906359","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 15/64\"","NDC":"08489601510"},{"Id":392186,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906362","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 15/64\"","NDC":"08489601710"},{"Id":392187,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"08489602009"},{"Id":392188,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"08489602109"},{"Id":392189,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"08489602209"},{"Id":392190,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08489602309"},{"Id":392191,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08489602409"},{"Id":392192,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08489602509"},{"Id":392193,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08489602609"},{"Id":392194,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08489602709"},{"Id":392195,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08489602809"},{"Id":392196,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08489605010"},{"Id":392197,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08489605110"},{"Id":392198,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08489605210"},{"Id":392199,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489749610"},{"Id":392200,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489749710"},{"Id":392201,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489749810"},{"Id":392202,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08489749910"},{"Id":392203,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489786609"},{"Id":392204,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489787009"},{"Id":392205,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489787209"},{"Id":392206,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489791010"},{"Id":392207,"FormularyType":"OHP","DrugName":"DROPLET MICR MIS 34GX9/64","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146385","GenericName":"INSULIN PEN NEEDLE 34 G X 3.5 MM (9/64\")","NDC":"08489791410"},{"Id":392208,"FormularyType":"OHP","DrugName":"DROPLET MICR MIS 34GX9/64","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146385","GenericName":"INSULIN PEN NEEDLE 34 G X 3.5 MM (9/64\")","NDC":"08489792010"},{"Id":392209,"FormularyType":"OHP","DrugName":"DROPSAFE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489816110"},{"Id":392210,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08489816210"},{"Id":392211,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489816310"},{"Id":392212,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX10MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146326","GenericName":"INSULIN PEN NEEDLE 29 G X 10 MM","NDC":"08489830710"},{"Id":392213,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08489830810"},{"Id":392214,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489830910"},{"Id":392215,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489831010"},{"Id":392216,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08489831110"},{"Id":392217,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489831210"},{"Id":392218,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08489831310"},{"Id":392219,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489831410"},{"Id":392220,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489831510"},{"Id":392221,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08489846710"},{"Id":392222,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489846810"},{"Id":392223,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08489846910"},{"Id":392224,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489847010"},{"Id":392225,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489847110"},{"Id":392226,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489847210"},{"Id":392227,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489889705"},{"Id":392228,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489889805"},{"Id":392229,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08489908011"},{"Id":392230,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"08489908111"},{"Id":392231,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX1/4","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08489908211"},{"Id":392232,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"08489908311"},{"Id":392233,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08496009501"},{"Id":392234,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08496009601"},{"Id":392235,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08496010101"},{"Id":392236,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08496010201"},{"Id":392237,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08496011601"},{"Id":392238,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496011701"},{"Id":392239,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08496011801"},{"Id":392240,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08496011901"},{"Id":392241,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08496012501"},{"Id":392242,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08496012601"},{"Id":392243,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08496012701"},{"Id":392244,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08496012801"},{"Id":392245,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08496012901"},{"Id":392246,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08496013001"},{"Id":392247,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08496013101"},{"Id":392248,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706340","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"08496013501"},{"Id":392249,"FormularyType":"OHP","DrugName":"1ML ALLR SYR MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08496013701"},{"Id":392250,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08496014001"},{"Id":392251,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS LUER 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08496015501"},{"Id":392252,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS UNI 3ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08496015801"},{"Id":392253,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS LUER 3ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08496015901"},{"Id":392254,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS UNI 5ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"08496016001"},{"Id":392255,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS LUER 5ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"08496016101"},{"Id":392256,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS UNI 10ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08496016201"},{"Id":392257,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS LUER10ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08496016301"},{"Id":392258,"FormularyType":"OHP","DrugName":"INSULIN SYR MIS BARR 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030056320","GenericName":"INSULIN SYRINGE (DISP) U-100 1 ML","NDC":"08496016401"},{"Id":392259,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS LUER 3ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08496017001"},{"Id":392260,"FormularyType":"OHP","DrugName":"SYRINGE BARR MIS LUER10ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"08496017201"},{"Id":392261,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 20ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08496017601"},{"Id":392262,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 60ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08496017801"},{"Id":392263,"FormularyType":"OHP","DrugName":"NEEDLES MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08496018601"},{"Id":392264,"FormularyType":"OHP","DrugName":"NEEDLES MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08496018701"},{"Id":392265,"FormularyType":"OHP","DrugName":"NEEDLES MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08496018801"},{"Id":392266,"FormularyType":"OHP","DrugName":"NEEDLES MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08496019001"},{"Id":392267,"FormularyType":"OHP","DrugName":"NEEDLES MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08496019201"},{"Id":392268,"FormularyType":"OHP","DrugName":"NEEDLES MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08496019401"},{"Id":392269,"FormularyType":"OHP","DrugName":"NEEDLES MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08496019501"},{"Id":392270,"FormularyType":"OHP","DrugName":"NEEDLES MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08496019601"},{"Id":392271,"FormularyType":"OHP","DrugName":"NEEDLES MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08496019801"},{"Id":392272,"FormularyType":"OHP","DrugName":"NEEDLES MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08496019901"},{"Id":392273,"FormularyType":"OHP","DrugName":"NEEDLES MIS 23GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236312","GenericName":"NEEDLE (DISP) 23 X 5/8\"","NDC":"08496020001"},{"Id":392274,"FormularyType":"OHP","DrugName":"NEEDLES MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08496020101"},{"Id":392275,"FormularyType":"OHP","DrugName":"NEEDLES MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"08496020201"},{"Id":392276,"FormularyType":"OHP","DrugName":"NEEDLES MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08496020301"},{"Id":392277,"FormularyType":"OHP","DrugName":"NEEDLES MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08496020401"},{"Id":392278,"FormularyType":"OHP","DrugName":"NEEDLES MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08496020501"},{"Id":392279,"FormularyType":"OHP","DrugName":"NEEDLES MIS 26X1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266305","GenericName":"NEEDLE (DISP) 26 X 1/2\"","NDC":"08496020601"},{"Id":392280,"FormularyType":"OHP","DrugName":"NEEDLES MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08496020701"},{"Id":392281,"FormularyType":"OHP","DrugName":"NEEDLES MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020286310","GenericName":"NEEDLE (DISP) 28 X 1/2\" (12.7 MM)","NDC":"08496021001"},{"Id":392282,"FormularyType":"OHP","DrugName":"NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020296310","GenericName":"NEEDLE (DISP) 29 X 1/2\" (12.7 MM)","NDC":"08496021601"},{"Id":392283,"FormularyType":"OHP","DrugName":"NEEDLES MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306305","GenericName":"NEEDLE (DISP) 30 X 1/2\"","NDC":"08496021701"},{"Id":392284,"FormularyType":"OHP","DrugName":"NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306303","GenericName":"NEEDLE (DISP) 30 X 5/16\" (8 MM)","NDC":"08496021801"},{"Id":392285,"FormularyType":"OHP","DrugName":"NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020316310","GenericName":"NEEDLE (DISP) 31 X 5/16\" (8 MM)","NDC":"08496021901"},{"Id":392286,"FormularyType":"OHP","DrugName":"NEEDLES MIS 22GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226315","GenericName":"NEEDLE (DISP) 22 X 3/4\"","NDC":"08496022001"},{"Id":392287,"FormularyType":"OHP","DrugName":"NEEDLES MIS 27GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276315","GenericName":"NEEDLE (DISP) 27 X 1\" (25 MM)","NDC":"08496022101"},{"Id":392288,"FormularyType":"OHP","DrugName":"NEEDLES MIS 22GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226315","GenericName":"NEEDLE (DISP) 22 X 3/4\"","NDC":"08496022201"},{"Id":392289,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 26GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706342","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 26 X 5/8\"","NDC":"08496023101"},{"Id":392290,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08496023201"},{"Id":392291,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496023301"},{"Id":392292,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08496023401"},{"Id":392293,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08496023601"},{"Id":392294,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016368","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"08496024201"},{"Id":392295,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016387","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08496024301"},{"Id":392296,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08496024501"},{"Id":392297,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08496024601"},{"Id":392298,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08496024801"},{"Id":392299,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036307","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1\"","NDC":"08496025201"},{"Id":392300,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036310","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1-1/2\"","NDC":"08496025301"},{"Id":392301,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036314","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 19 X 1\" (25 MM)","NDC":"08496025401"},{"Id":392302,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036315","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 19 X 1.5\" (40 MM)","NDC":"08496025501"},{"Id":392303,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08496025601"},{"Id":392304,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"08496025701"},{"Id":392305,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08496025801"},{"Id":392306,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08496025901"},{"Id":392307,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08496026101"},{"Id":392308,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08496026201"},{"Id":392309,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08496026301"},{"Id":392310,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08496026401"},{"Id":392311,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08496026501"},{"Id":392312,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056316","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 18 X 1\" (25 MM)","NDC":"08496027401"},{"Id":392313,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056325","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1-1/2\"","NDC":"08496027501"},{"Id":392314,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056320","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1\"","NDC":"08496027601"},{"Id":392315,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056330","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1\"","NDC":"08496027701"},{"Id":392316,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"08496027801"},{"Id":392317,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"08496028001"},{"Id":392318,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056375","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 25 X 5/8\" (16 MM)","NDC":"08496028201"},{"Id":392319,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056372","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 25 X 1\" (25 MM)","NDC":"08496028301"},{"Id":392320,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106310","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 18G X 1.5\" (40 MM)","NDC":"08496028401"},{"Id":392321,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106307","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 18G X 1\" (25 MM)","NDC":"08496028501"},{"Id":392322,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106325","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 20 X 1-1/2\"","NDC":"08496028601"},{"Id":392323,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106320","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 20 X 1\"","NDC":"08496028701"},{"Id":392324,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106340","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1-1/2\"","NDC":"08496028801"},{"Id":392325,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106330","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1\"","NDC":"08496029001"},{"Id":392326,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106360","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 22 X 1-1/2\"","NDC":"08496029101"},{"Id":392327,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106382","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 25 X 1\" (25 MM)","NDC":"08496029201"},{"Id":392328,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"08496029301"},{"Id":392329,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166320","GenericName":"NEEDLE (DISP) 16 X 1\"","NDC":"08496030301"},{"Id":392330,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166330","GenericName":"NEEDLE (DISP) 16 X 1-1/2\"","NDC":"08496030401"},{"Id":392331,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08496030501"},{"Id":392332,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08496030601"},{"Id":392333,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186325","GenericName":"NEEDLE (DISP) 18 X 1.25\" (30 MM)","NDC":"08496030701"},{"Id":392334,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08496030801"},{"Id":392335,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08496030901"},{"Id":392336,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08496031101"},{"Id":392337,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08496031201"},{"Id":392338,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08496031301"},{"Id":392339,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08496031401"},{"Id":392340,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08496031801"},{"Id":392341,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08496031901"},{"Id":392342,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236315","GenericName":"NEEDLE (DISP) 23 X 3/4\"","NDC":"08496032101"},{"Id":392343,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08496032201"},{"Id":392344,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236325","GenericName":"NEEDLE (DISP) 23 X 1-1/4\"","NDC":"08496032301"},{"Id":392345,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"08496032401"},{"Id":392346,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 24GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020246320","GenericName":"NEEDLE (DISP) 24 X 1\"","NDC":"08496032701"},{"Id":392347,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 24GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020246325","GenericName":"NEEDLE (DISP) 24 X 1.25\" (30 MM)","NDC":"08496032801"},{"Id":392348,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08496032901"},{"Id":392349,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08496033101"},{"Id":392350,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08496033201"},{"Id":392351,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266305","GenericName":"NEEDLE (DISP) 26 X 1/2\"","NDC":"08496033501"},{"Id":392352,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266304","GenericName":"NEEDLE (DISP) 26 X 3/8\"","NDC":"08496033701"},{"Id":392353,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266310","GenericName":"NEEDLE (DISP) 26 X 5/8\"","NDC":"08496033801"},{"Id":392354,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08496033901"},{"Id":392355,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276325","GenericName":"NEEDLE (DISP) 27 X 1-1/4\"","NDC":"08496034001"},{"Id":392356,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276330","GenericName":"NEEDLE (DISP) 27 X 1-1/2\"","NDC":"08496034101"},{"Id":392357,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306305","GenericName":"NEEDLE (DISP) 30 X 1/2\"","NDC":"08496034801"},{"Id":392358,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 30G X 1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306320","GenericName":"NEEDLE (DISP) 30 X 1\"","NDC":"08496035001"},{"Id":392359,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020316310","GenericName":"NEEDLE (DISP) 31 X 5/16\" (8 MM)","NDC":"08496035101"},{"Id":392360,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 32GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020326310","GenericName":"NEEDLE (DISP) 32 X 5/16\" (8 MM)","NDC":"08496035201"},{"Id":392361,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08496036301"},{"Id":392362,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08496036401"},{"Id":392363,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496038801"},{"Id":392364,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08496038901"},{"Id":392365,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08496039001"},{"Id":392366,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08496039601"},{"Id":392367,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08496039801"},{"Id":392368,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08496040201"},{"Id":392369,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08496040401"},{"Id":392370,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08496040501"},{"Id":392371,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08496040601"},{"Id":392372,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08496040701"},{"Id":392373,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08496040801"},{"Id":392374,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08496040901"},{"Id":392375,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"08496042001"},{"Id":392376,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"08496042201"},{"Id":392377,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056372","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 25 X 1\" (25 MM)","NDC":"08496042301"},{"Id":392378,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106340","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1-1/2\"","NDC":"08496042901"},{"Id":392379,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106360","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 22 X 1-1/2\"","NDC":"08496043101"},{"Id":392380,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106382","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 25 X 1\" (25 MM)","NDC":"08496043201"},{"Id":392381,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08496043401"},{"Id":392382,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 26GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016370","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 26 X 5/8\"","NDC":"08496044501"},{"Id":392383,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08496044601"},{"Id":392384,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08496044701"},{"Id":392385,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08496271501"},{"Id":392386,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08496271511"},{"Id":392387,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"08496275501"},{"Id":392388,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"08496275511"},{"Id":392389,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08496281501"},{"Id":392390,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08496281511"},{"Id":392391,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08496285501"},{"Id":392392,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08496285511"},{"Id":392393,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08496290201"},{"Id":392394,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08496290205"},{"Id":392395,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 29GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146318","GenericName":"INSULIN PEN NEEDLE 29 G X 5 MM (1/5\" OR 3/16\")","NDC":"08496290501"},{"Id":392396,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 29GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146322","GenericName":"INSULIN PEN NEEDLE 29 G X 8 MM (1/3\" OR 5/16\")","NDC":"08496290801"},{"Id":392397,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496291501"},{"Id":392398,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496291511"},{"Id":392399,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08496295501"},{"Id":392400,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08496295511"},{"Id":392401,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"08496300301"},{"Id":392402,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08496300501"},{"Id":392403,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146341","GenericName":"INSULIN PEN NEEDLE 30 G X 6 MM (1/4\" OR 15/64\")","NDC":"08496300701"},{"Id":392404,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"08496300801"},{"Id":392405,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08496301501"},{"Id":392406,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08496301511"},{"Id":392407,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08496301601"},{"Id":392408,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08496301611"},{"Id":392409,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166320","GenericName":"NEEDLE (DISP) 16 X 1\"","NDC":"08496303001"},{"Id":392410,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08496303501"},{"Id":392411,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"08496303511"},{"Id":392412,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08496303601"},{"Id":392413,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08496303611"},{"Id":392414,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08496305501"},{"Id":392415,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"08496305511"},{"Id":392416,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08496305601"},{"Id":392417,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08496305611"},{"Id":392418,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08496310101"},{"Id":392419,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08496310305"},{"Id":392420,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08496310401"},{"Id":392421,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08496310405"},{"Id":392422,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08496310601"},{"Id":392423,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08496310605"},{"Id":392424,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08496311601"},{"Id":392425,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08496311611"},{"Id":392426,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08496313601"},{"Id":392427,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08496313611"},{"Id":392428,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08496315601"},{"Id":392429,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08496315611"},{"Id":392430,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"08496320101"},{"Id":392431,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 32GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"08496320105"},{"Id":392432,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08496320401"},{"Id":392433,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08496320405"},{"Id":392434,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08496320801"},{"Id":392435,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08496320805"},{"Id":392436,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08496651001"},{"Id":392437,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08496651101"},{"Id":392438,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496651201"},{"Id":392439,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"08496652001"},{"Id":392440,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08496652101"},{"Id":392441,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08496652201"},{"Id":392442,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906360","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 5/8\"","NDC":"08496702001"},{"Id":392443,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08496791501"},{"Id":392444,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"08496801501"},{"Id":392445,"FormularyType":"OHP","DrugName":"OMNIPOD DASH KIT PDM","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506400","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP KIT***","NDC":"08508200000"},{"Id":392446,"FormularyType":"OHP","DrugName":"OMNIPOD DASH MIS PODS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506300","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP RESERVOIR***","NDC":"08508200005"},{"Id":392447,"FormularyType":"OHP","DrugName":"OMNIPOD DASH KIT INTRO","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506400","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP KIT***","NDC":"08508200032"},{"Id":392448,"FormularyType":"OHP","DrugName":"OMNIPOD 5 DX KIT INT G7G6","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506400","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP KIT***","NDC":"08508300001"},{"Id":392449,"FormularyType":"OHP","DrugName":"OMNIPOD 5 DX MIS POD G7G6","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506300","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP RESERVOIR***","NDC":"08508300021"},{"Id":392450,"FormularyType":"OHP","DrugName":"OMNIPOD 5 L2 MIS PODS G6","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506300","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP RESERVOIR***","NDC":"08508300042"},{"Id":392451,"FormularyType":"OHP","DrugName":"OMNIPOD 5 DX MIS POD G7G6","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506300","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP RESERVOIR***","NDC":"08508300075"},{"Id":392452,"FormularyType":"OHP","DrugName":"OMNIPOD 5 L2 KIT INTRO G6","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506400","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP KIT***","NDC":"08508300088"},{"Id":392453,"FormularyType":"OHP","DrugName":"PENTIPS MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08517042987"},{"Id":392454,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517043087"},{"Id":392455,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517044087"},{"Id":392456,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517045087"},{"Id":392457,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517049087"},{"Id":392458,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08517052988"},{"Id":392459,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517053085"},{"Id":392460,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517053087"},{"Id":392461,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517053088"},{"Id":392462,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517054085"},{"Id":392463,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517054087"},{"Id":392464,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517054088"},{"Id":392465,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517055085"},{"Id":392466,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517055087"},{"Id":392467,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517055088"},{"Id":392468,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517059085"},{"Id":392469,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517059587"},{"Id":392470,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517059588"},{"Id":392471,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517064000"},{"Id":392472,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517064100"},{"Id":392473,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517065000"},{"Id":392474,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517065100"},{"Id":392475,"FormularyType":"OHP","DrugName":"PENTIPS MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08517342901"},{"Id":392476,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517343001"},{"Id":392477,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517344001"},{"Id":392478,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517345001"},{"Id":392479,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517349001"},{"Id":392480,"FormularyType":"OHP","DrugName":"1ST TIER UNI MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08517352936"},{"Id":392481,"FormularyType":"OHP","DrugName":"1ST TIER UNI MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517353036"},{"Id":392482,"FormularyType":"OHP","DrugName":"1ST TIER UNI MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517354036"},{"Id":392483,"FormularyType":"OHP","DrugName":"1ST TIER UNI MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517355036"},{"Id":392484,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517356036"},{"Id":392485,"FormularyType":"OHP","DrugName":"1ST TIER UNI MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517359036"},{"Id":392486,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517359536"},{"Id":392487,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08517382919"},{"Id":392488,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"08517382936"},{"Id":392489,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517383019"},{"Id":392490,"FormularyType":"OHP","DrugName":"TIER UNI PLS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517383036"},{"Id":392491,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08517383065"},{"Id":392492,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517384019"},{"Id":392493,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517384036"},{"Id":392494,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517384065"},{"Id":392495,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517385019"},{"Id":392496,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517385036"},{"Id":392497,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08517385065"},{"Id":392498,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"08517386036"},{"Id":392499,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517389019"},{"Id":392500,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"08517389036"},{"Id":392501,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08521000131"},{"Id":392502,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08521000231"},{"Id":392503,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08521000331"},{"Id":392504,"FormularyType":"OHP","DrugName":"FIFTY50 PREP PAD PADS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"08521080100"},{"Id":392505,"FormularyType":"OHP","DrugName":"FIFTY50 PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08521500432"},{"Id":392506,"FormularyType":"OHP","DrugName":"FIFTY50 MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08521500531"},{"Id":392507,"FormularyType":"OHP","DrugName":"FIFTY50 PEN MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08521500632"},{"Id":392508,"FormularyType":"OHP","DrugName":"FIFTY50 PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08521500831"},{"Id":392509,"FormularyType":"OHP","DrugName":"FIFTY50 PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"08521550432"},{"Id":392510,"FormularyType":"OHP","DrugName":"FIFTY50 MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"08521550531"},{"Id":392511,"FormularyType":"OHP","DrugName":"FIFTY50 PEN MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"08521550632"},{"Id":392512,"FormularyType":"OHP","DrugName":"FIFTY50 MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"08521550831"},{"Id":392513,"FormularyType":"OHP","DrugName":"RESTORE CONT PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"08567509378"},{"Id":392514,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08587183529"},{"Id":392515,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08587183530"},{"Id":392516,"FormularyType":"OHP","DrugName":"RITEFLO MIS","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"08591601001"},{"Id":392517,"FormularyType":"OHP","DrugName":"CLINITEST KIT SELF-TST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"08620115621"},{"Id":392518,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS REG TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08881103025"},{"Id":392519,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08881106028"},{"Id":392520,"FormularyType":"OHP","DrugName":"140ML SYRING MIS REG TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006390","GenericName":"SYRINGE (DISPOSABLE) 140 ML","NDC":"08881114014"},{"Id":392521,"FormularyType":"OHP","DrugName":"140ML SYRING MIS LUER-LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006390","GenericName":"SYRINGE (DISPOSABLE) 140 ML","NDC":"08881114030"},{"Id":392522,"FormularyType":"OHP","DrugName":"140ML SYRING MIS CATH TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006390","GenericName":"SYRINGE (DISPOSABLE) 140 ML","NDC":"08881114055"},{"Id":392523,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS REG TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08881120037"},{"Id":392524,"FormularyType":"OHP","DrugName":"35ML SYRINGE MIS ECC LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08881135068"},{"Id":392525,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS CATH TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881160157"},{"Id":392526,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 14GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020146330","GenericName":"NEEDLE (DISP) 14 X 1-1/2\"","NDC":"08881200011"},{"Id":392527,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166330","GenericName":"NEEDLE (DISP) 16 X 1-1/2\"","NDC":"08881200037"},{"Id":392528,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166330","GenericName":"NEEDLE (DISP) 16 X 1-1/2\"","NDC":"08881200045"},{"Id":392529,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166320","GenericName":"NEEDLE (DISP) 16 X 1\"","NDC":"08881200052"},{"Id":392530,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166315","GenericName":"NEEDLE (DISP) 16 X 3/4\"","NDC":"08881200060"},{"Id":392531,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08881200078"},{"Id":392532,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08881200086"},{"Id":392533,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08881200110"},{"Id":392534,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08881200136"},{"Id":392535,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08881200144"},{"Id":392536,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08881200169"},{"Id":392537,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08881200185"},{"Id":392538,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08881200193"},{"Id":392539,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08881200219"},{"Id":392540,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216335","GenericName":"NEEDLE (DISP) 21 X 2\"","NDC":"08881200318"},{"Id":392541,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08881200326"},{"Id":392542,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08881200342"},{"Id":392543,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08881200383"},{"Id":392544,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256325","GenericName":"NEEDLE (DISP) 25 X 1-1/4\"","NDC":"08881200433"},{"Id":392545,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256350","GenericName":"NEEDLE (DISP) 25 X 2\"","NDC":"08881200441"},{"Id":392546,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08881200466"},{"Id":392547,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276325","GenericName":"NEEDLE (DISP) 27 X 1-1/4\"","NDC":"08881200508"},{"Id":392548,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08881200516"},{"Id":392549,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 14GX2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020146350","GenericName":"NEEDLE (DISP) 14 X 2\"","NDC":"08881200573"},{"Id":392550,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08881200714"},{"Id":392551,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 16GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020166312","GenericName":"NEEDLE (DISP) 16 X 5/8\"","NDC":"08881200755"},{"Id":392552,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 14GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020146320","GenericName":"NEEDLE (DISP) 14 X 1\"","NDC":"08881200805"},{"Id":392553,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036307","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1\"","NDC":"08881202033"},{"Id":392554,"FormularyType":"OHP","DrugName":"BLUNT CANNUL MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08881202363"},{"Id":392555,"FormularyType":"OHP","DrugName":"BLUNT CANNUL MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08881202371"},{"Id":392556,"FormularyType":"OHP","DrugName":"TRANSFER NDL MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020006300","GenericName":"HYPODERMIC NEEDLES (DISPOSABLE)","NDC":"08881204005"},{"Id":392557,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08881250016"},{"Id":392558,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08881250024"},{"Id":392559,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 30GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306315","GenericName":"NEEDLE (DISP) 30 X 3/4\"","NDC":"08881250032"},{"Id":392560,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08881250040"},{"Id":392561,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08881250057"},{"Id":392562,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08881250065"},{"Id":392563,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08881250073"},{"Id":392564,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08881250081"},{"Id":392565,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08881250099"},{"Id":392566,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08881250107"},{"Id":392567,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08881250115"},{"Id":392568,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08881250123"},{"Id":392569,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08881250149"},{"Id":392570,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08881250172"},{"Id":392571,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08881250206"},{"Id":392572,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08881250214"},{"Id":392573,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08881250222"},{"Id":392574,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08881250230"},{"Id":392575,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08881250255"},{"Id":392576,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236315","GenericName":"NEEDLE (DISP) 23 X 3/4\"","NDC":"08881250289"},{"Id":392577,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08881250305"},{"Id":392578,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08881250313"},{"Id":392579,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266305","GenericName":"NEEDLE (DISP) 26 X 1/2\"","NDC":"08881250321"},{"Id":392580,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"08881250362"},{"Id":392581,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"08881250545"},{"Id":392582,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08881500014"},{"Id":392583,"FormularyType":"OHP","DrugName":"TB SYRINGE MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706321","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1/2 ML 28 X 1/2\"","NDC":"08881500105"},{"Id":392584,"FormularyType":"OHP","DrugName":"ALLERGIST KIT 0.5/28G","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706424","GenericName":"ALLERGY TRAY KIT 1/2 ML 28 X 1/2\"","NDC":"08881500501"},{"Id":392585,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08881501160"},{"Id":392586,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706340","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"08881501178"},{"Id":392587,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08881501210"},{"Id":392588,"FormularyType":"OHP","DrugName":"ALLERGIST KIT 1MLX28G","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706465","GenericName":"ALLERGY TRAY KIT 1 ML 28 X 1/2\"","NDC":"08881501236"},{"Id":392589,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08881501368"},{"Id":392590,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030056320","GenericName":"INSULIN SYRINGE (DISP) U-100 1 ML","NDC":"08881501384"},{"Id":392591,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08881501400"},{"Id":392592,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 1ML/REG","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"08881501459"},{"Id":392593,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08881501608"},{"Id":392594,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/25G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906330","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 25 X 5/8\"","NDC":"08881501822"},{"Id":392595,"FormularyType":"OHP","DrugName":"ALLERGIST KIT 1MLX27G","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706460","GenericName":"ALLERGY TRAY KIT 1 ML 27 X 1/2\"","NDC":"08881501962"},{"Id":392596,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"08881501970"},{"Id":392597,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08881511110"},{"Id":392598,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08881511136"},{"Id":392599,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08881511144"},{"Id":392600,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08881511201"},{"Id":392601,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08881511235"},{"Id":392602,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08881511310"},{"Id":392603,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08881511336"},{"Id":392604,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08881511344"},{"Id":392605,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 12ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006312","GenericName":"SYRINGE (DISPOSABLE) 12 ML","NDC":"08881512258"},{"Id":392606,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS LUER-LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006312","GenericName":"SYRINGE (DISPOSABLE) 12 ML","NDC":"08881512878"},{"Id":392607,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006312","GenericName":"SYRINGE (DISPOSABLE) 12 ML","NDC":"08881512977"},{"Id":392608,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 20GX3/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036317","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 3/4\"","NDC":"08881513025"},{"Id":392609,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08881513033"},{"Id":392610,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"08881513058"},{"Id":392611,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08881513132"},{"Id":392612,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08881513157"},{"Id":392613,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 3ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08881513207"},{"Id":392614,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08881513231"},{"Id":392615,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08881513256"},{"Id":392616,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08881513330"},{"Id":392617,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08881513512"},{"Id":392618,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08881513538"},{"Id":392619,"FormularyType":"OHP","DrugName":"3ML LL SYRNG MIS 27GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036390","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 27 X 1-1/4\"","NDC":"08881513744"},{"Id":392620,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08881513918"},{"Id":392621,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"08881513934"},{"Id":392622,"FormularyType":"OHP","DrugName":"6ML LL SYRNG MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066325","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 20 X 1-1/2\"","NDC":"08881516051"},{"Id":392623,"FormularyType":"OHP","DrugName":"6ML LL SYRNG MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066330","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 21 X 1\"","NDC":"08881516135"},{"Id":392624,"FormularyType":"OHP","DrugName":"6ML LL SYRNG MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066340","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 21 X 1-1/2\"","NDC":"08881516150"},{"Id":392625,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 6ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08881516200"},{"Id":392626,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS REG TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08881516911"},{"Id":392627,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006306","GenericName":"SYRINGE (DISPOSABLE) 6 ML","NDC":"08881516937"},{"Id":392628,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08881520178"},{"Id":392629,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 20ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08881520251"},{"Id":392630,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08881520657"},{"Id":392631,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS ECC LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08881520665"},{"Id":392632,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"08881520673"},{"Id":392633,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 35ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08881535101"},{"Id":392634,"FormularyType":"OHP","DrugName":"35ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08881535762"},{"Id":392635,"FormularyType":"OHP","DrugName":"35ML SYRINGE MIS CATH TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08881535770"},{"Id":392636,"FormularyType":"OHP","DrugName":"35ML SYRINGE MIS ECC LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08881535788"},{"Id":392637,"FormularyType":"OHP","DrugName":"35ML SYRINGE MIS REG LUER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"08881535796"},{"Id":392638,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER-LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881560125"},{"Id":392639,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS CATH TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881560141"},{"Id":392640,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS ECC TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881560182"},{"Id":392641,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS REG TIP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881560224"},{"Id":392642,"FormularyType":"OHP","DrugName":"PHARM TRAY MIS 60ML/LL","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881560232"},{"Id":392643,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS TOOMEY","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"08881560265"},{"Id":392644,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08881600004"},{"Id":392645,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08881600145"},{"Id":392646,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08881600350"},{"Id":392647,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08881600651"},{"Id":392648,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08881600700"},{"Id":392649,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08881600800"},{"Id":392650,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08881601101"},{"Id":392651,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08881601358"},{"Id":392652,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08881601600"},{"Id":392653,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08881608203"},{"Id":392654,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08881608303"},{"Id":392655,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08881608311"},{"Id":392656,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"08881609004"},{"Id":392657,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"08881609101"},{"Id":392658,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"08881609131"},{"Id":392659,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08881609145"},{"Id":392660,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"08881609231"},{"Id":392661,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"08881609331"},{"Id":392662,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08881609350"},{"Id":392663,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08881609358"},{"Id":392664,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08881609600"},{"Id":392665,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08881609700"},{"Id":392666,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08881609800"},{"Id":392667,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016340","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 23 X 1\"","NDC":"08881811310"},{"Id":392668,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"08881811510"},{"Id":392669,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"08881811558"},{"Id":392670,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126325","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 20 X 1-1/2\"","NDC":"08881822015"},{"Id":392671,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126330","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 21 X 1\"","NDC":"08881822110"},{"Id":392672,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126335","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 21 X 1-1/2\"","NDC":"08881822115"},{"Id":392673,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126360","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 22 X 1-1/2\"","NDC":"08881822215"},{"Id":392674,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126305","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 18 X 1\"","NDC":"08881822810"},{"Id":392675,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"08881833010"},{"Id":392676,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"08881833015"},{"Id":392677,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"08881833110"},{"Id":392678,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"08881833115"},{"Id":392679,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"08881833210"},{"Id":392680,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"08881833215"},{"Id":392681,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"08881833310"},{"Id":392682,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"08881833510"},{"Id":392683,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"08881833558"},{"Id":392684,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"08881850010"},{"Id":392685,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"08881850015"},{"Id":392686,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"08881850110"},{"Id":392687,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"08881850115"},{"Id":392688,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 21GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216312","GenericName":"NEEDLE (DISP) 21 X 5/8\"","NDC":"08881850158"},{"Id":392689,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"08881850210"},{"Id":392690,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"08881850215"},{"Id":392691,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"08881850310"},{"Id":392692,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 23GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236312","GenericName":"NEEDLE (DISP) 23 X 5/8\"","NDC":"08881850358"},{"Id":392693,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"08881850510"},{"Id":392694,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"08881850558"},{"Id":392695,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"08881850810"},{"Id":392696,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"08881850815"},{"Id":392697,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 19GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196320","GenericName":"NEEDLE (DISP) 19 X 1\"","NDC":"08881850910"},{"Id":392698,"FormularyType":"OHP","DrugName":"SAFTY NEEDLE MIS 19GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020196330","GenericName":"NEEDLE (DISP) 19 X 1-1/2\"","NDC":"08881850915"},{"Id":392699,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066325","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 20 X 1-1/2\"","NDC":"08881866015"},{"Id":392700,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066330","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 21 X 1\"","NDC":"08881866110"},{"Id":392701,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066340","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 21 X 1-1/2\"","NDC":"08881866115"},{"Id":392702,"FormularyType":"OHP","DrugName":"6ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040066360","GenericName":"SYRINGE/NEEDLE (DISP) 6 ML 22 X 1-1/2\"","NDC":"08881866215"},{"Id":392703,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"08881882712"},{"Id":392704,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706360","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"08881882812"},{"Id":392705,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"08881892910"},{"Id":392706,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"08881892930"},{"Id":392707,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"08881892950"},{"Id":392708,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"08881893010"},{"Id":392709,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"08881893030"},{"Id":392710,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"08881893050"},{"Id":392711,"FormularyType":"OHP","DrugName":"OHC COVID-19 KIT ANTIGEN","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"09115090565"},{"Id":392712,"FormularyType":"OHP","DrugName":"VITAMIN B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"10006070011"},{"Id":392713,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10006070012"},{"Id":392714,"FormularyType":"OHP","DrugName":"MAGDELAY TAB 64MG","DosageForm":"TBEC - Tablet DR","Strength":"64","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010200614","GenericName":"MAGNESIUM CHLORIDE TAB DR 64 MG (ELEMENTAL MG)","NDC":"10006070013"},{"Id":392715,"FormularyType":"OHP","DrugName":"NIACIN CAP 250MG TR","DosageForm":"CPCR - Capsule ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000210","GenericName":"NIACIN CAP ER 250 MG","NDC":"10006070020"},{"Id":392716,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"10006070022"},{"Id":392717,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"10006070028"},{"Id":392718,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"10006070038"},{"Id":392719,"FormularyType":"OHP","DrugName":"IRON TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"10006073013"},{"Id":392720,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10006073016"},{"Id":392721,"FormularyType":"OHP","DrugName":"VITAMIN B6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10006073017"},{"Id":392722,"FormularyType":"OHP","DrugName":"VITAMIN B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"10006073021"},{"Id":392723,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"10006073038"},{"Id":392724,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000310","GenericName":"CYCLOPHOSPHAMIDE TAB 50 MG","NDC":"10019098401"},{"Id":392725,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000310","GenericName":"CYCLOPHOSPHAMIDE TAB 50 MG","NDC":"10019098409"},{"Id":392726,"FormularyType":"OHP","DrugName":"FASTEP 1-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063031"},{"Id":392727,"FormularyType":"OHP","DrugName":"FASTEP 2-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063035"},{"Id":392728,"FormularyType":"OHP","DrugName":"FASTEP 4-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063036"},{"Id":392729,"FormularyType":"OHP","DrugName":"FASTEP 5-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063037"},{"Id":392730,"FormularyType":"OHP","DrugName":"FASTEP 25-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063038"},{"Id":392731,"FormularyType":"OHP","DrugName":"FASTEP 1-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063041"},{"Id":392732,"FormularyType":"OHP","DrugName":"FASTEP 2-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063042"},{"Id":392733,"FormularyType":"OHP","DrugName":"FASTEP 4-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063043"},{"Id":392734,"FormularyType":"OHP","DrugName":"FASTEP 20-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"10022063044"},{"Id":392735,"FormularyType":"OHP","DrugName":"YUMVS VIT D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"10048061067"},{"Id":392736,"FormularyType":"OHP","DrugName":"YUMVS VIT D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"10048061145"},{"Id":392737,"FormularyType":"OHP","DrugName":"YUMVS VIT D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"10048061217"},{"Id":392738,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"10048061233"},{"Id":392739,"FormularyType":"OHP","DrugName":"YUMVS MELATO CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"10048061291"},{"Id":392740,"FormularyType":"OHP","DrugName":"LUCIRA KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356410","GenericName":"COVID-19 AT HOME MOLECULAR TEST KIT","NDC":"10055097000"},{"Id":392741,"FormularyType":"OHP","DrugName":"LUCIRA CHECK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356410","GenericName":"COVID-19 AT HOME MOLECULAR TEST KIT","NDC":"10055097004"},{"Id":392742,"FormularyType":"OHP","DrugName":"AQINJECT PEN MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"10118089025"},{"Id":392743,"FormularyType":"OHP","DrugName":"AQINJECT PEN MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"10118089028"},{"Id":392744,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"10118089032"},{"Id":392745,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"10118089036"},{"Id":392746,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"10118089040"},{"Id":392747,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011101"},{"Id":392748,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011103"},{"Id":392749,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011110"},{"Id":392750,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011113"},{"Id":392751,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011130"},{"Id":392752,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011160"},{"Id":392753,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011162"},{"Id":392754,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011167"},{"Id":392755,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10135011190"},{"Id":392756,"FormularyType":"OHP","DrugName":"PYRIDOXINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000305","GenericName":"PYRIDOXINE HCL TAB 25 MG","NDC":"10135011910"},{"Id":392757,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012305"},{"Id":392758,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012310"},{"Id":392759,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012324"},{"Id":392760,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012330"},{"Id":392761,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012350"},{"Id":392762,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012360"},{"Id":392763,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012362"},{"Id":392764,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012365"},{"Id":392765,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012370"},{"Id":392766,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135012390"},{"Id":392767,"FormularyType":"OHP","DrugName":"THIAMINE HCL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"10135013201"},{"Id":392768,"FormularyType":"OHP","DrugName":"THIAMINE HCL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"10135013210"},{"Id":392769,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"10135013301"},{"Id":392770,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"10135013324"},{"Id":392771,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"10135013330"},{"Id":392772,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"10135013362"},{"Id":392773,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"10135013369"},{"Id":392774,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10135013601"},{"Id":392775,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10135013605"},{"Id":392776,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10135013610"},{"Id":392777,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10135013613"},{"Id":392778,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10135013630"},{"Id":392779,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10135013660"},{"Id":392780,"FormularyType":"OHP","DrugName":"SORBITOL SOL 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600070002040","GenericName":"SORBITOL ORAL SOLUTION 70%","NDC":"10135013708"},{"Id":392781,"FormularyType":"OHP","DrugName":"SORBITOL SOL 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600070002040","GenericName":"SORBITOL ORAL SOLUTION 70%","NDC":"10135013718"},{"Id":392782,"FormularyType":"OHP","DrugName":"PYRIDOXINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10135013910"},{"Id":392783,"FormularyType":"OHP","DrugName":"PYRIDOXINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10135013930"},{"Id":392784,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014405"},{"Id":392785,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014410"},{"Id":392786,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014424"},{"Id":392787,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014450"},{"Id":392788,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014460"},{"Id":392789,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014466"},{"Id":392790,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135014470"},{"Id":392791,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"10135014614"},{"Id":392792,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"10135014617"},{"Id":392793,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10135014901"},{"Id":392794,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10135014910"},{"Id":392795,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10135014924"},{"Id":392796,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10135015005"},{"Id":392797,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10135015010"},{"Id":392798,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10135015020"},{"Id":392799,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10135015024"},{"Id":392800,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10135015030"},{"Id":392801,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10135015069"},{"Id":392802,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"10135015110"},{"Id":392803,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"10135015124"},{"Id":392804,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"10135015150"},{"Id":392805,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015201"},{"Id":392806,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015210"},{"Id":392807,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015213"},{"Id":392808,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015224"},{"Id":392809,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015230"},{"Id":392810,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015250"},{"Id":392811,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015260"},{"Id":392812,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015266"},{"Id":392813,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135015270"},{"Id":392814,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10135015401"},{"Id":392815,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10135015410"},{"Id":392816,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10135015425"},{"Id":392817,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10135015450"},{"Id":392818,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10135015461"},{"Id":392819,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"10135015601"},{"Id":392820,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"10135015610"},{"Id":392821,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"10135015613"},{"Id":392822,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"10135016101"},{"Id":392823,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135016313"},{"Id":392824,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135016314"},{"Id":392825,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10135016613"},{"Id":392826,"FormularyType":"OHP","DrugName":"PYRIDOXINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10135016713"},{"Id":392827,"FormularyType":"OHP","DrugName":"CHILDRENS CHW VITAMINS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"10135017010"},{"Id":392828,"FormularyType":"OHP","DrugName":"CHILDRENS CHW VITAMINS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"10135017060"},{"Id":392829,"FormularyType":"OHP","DrugName":"CHILDRENS CHW VITAMINS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"10135017069"},{"Id":392830,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135017301"},{"Id":392831,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135017305"},{"Id":392832,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135017310"},{"Id":392833,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135017336"},{"Id":392834,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135017362"},{"Id":392835,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135017369"},{"Id":392836,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"10135018001"},{"Id":392837,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"10135018010"},{"Id":392838,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"10135018101"},{"Id":392839,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"10135018110"},{"Id":392840,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"10135018201"},{"Id":392841,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"10135018210"},{"Id":392842,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10135018301"},{"Id":392843,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10135018305"},{"Id":392844,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10135018310"},{"Id":392845,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"10135018601"},{"Id":392846,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"10135018610"},{"Id":392847,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"10135019101"},{"Id":392848,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"10135019110"},{"Id":392849,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"10135019160"},{"Id":392850,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"10135019168"},{"Id":392851,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"10135019190"},{"Id":392852,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"10135021101"},{"Id":392853,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"10135021103"},{"Id":392854,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"10135021110"},{"Id":392855,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"10135021113"},{"Id":392856,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"10135021160"},{"Id":392857,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"10135021164"},{"Id":392858,"FormularyType":"OHP","DrugName":"ASPIRIN CHLD CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"10135024036"},{"Id":392859,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"10135024313"},{"Id":392860,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"10135024319"},{"Id":392861,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"10135031401"},{"Id":392862,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"10135031410"},{"Id":392863,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"10135040401"},{"Id":392864,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"10135040405"},{"Id":392865,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"10135040410"},{"Id":392866,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"10135049201"},{"Id":392867,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"10135049205"},{"Id":392868,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"10135049210"},{"Id":392869,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"10135049301"},{"Id":392870,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"10135049305"},{"Id":392871,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"10135049310"},{"Id":392872,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"10135049501"},{"Id":392873,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"10135049510"},{"Id":392874,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100310","GenericName":"BETHANECHOL CHLORIDE TAB 5 MG","NDC":"10135051501"},{"Id":392875,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"10135051601"},{"Id":392876,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"10135051701"},{"Id":392877,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"10135051705"},{"Id":392878,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100340","GenericName":"BETHANECHOL CHLORIDE TAB 50 MG","NDC":"10135051801"},{"Id":392879,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"10135052001"},{"Id":392880,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"10135052010"},{"Id":392881,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"10135052101"},{"Id":392882,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"10135052201"},{"Id":392883,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"10135052205"},{"Id":392884,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"10135052210"},{"Id":392885,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"10135052403"},{"Id":392886,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"10135052405"},{"Id":392887,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"10135052410"},{"Id":392888,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"10135052490"},{"Id":392889,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"10135052503"},{"Id":392890,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"10135052505"},{"Id":392891,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"10135052510"},{"Id":392892,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"10135052590"},{"Id":392893,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"10135052603"},{"Id":392894,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"10135052605"},{"Id":392895,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"10135052610"},{"Id":392896,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"10135052690"},{"Id":392897,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"10135053201"},{"Id":392898,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"10135053210"},{"Id":392899,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"10135053301"},{"Id":392900,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"10135053305"},{"Id":392901,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"10135053310"},{"Id":392902,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"10135054001"},{"Id":392903,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"10135054005"},{"Id":392904,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"10135054101"},{"Id":392905,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"10135054110"},{"Id":392906,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"10135054301"},{"Id":392907,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"10135056701"},{"Id":392908,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"10135056919"},{"Id":392909,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"10135057901"},{"Id":392910,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"10135057932"},{"Id":392911,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"10135058001"},{"Id":392912,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"10135058032"},{"Id":392913,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"10135058101"},{"Id":392914,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"10135058110"},{"Id":392915,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"10135058362"},{"Id":392916,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"10135058401"},{"Id":392917,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"10135058430"},{"Id":392918,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"10135058901"},{"Id":392919,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100320","GenericName":"PILOCARPINE HCL TAB 7.5 MG","NDC":"10135059001"},{"Id":392920,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"10135059601"},{"Id":392921,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"10135059797"},{"Id":392922,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"10135059798"},{"Id":392923,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"10135059799"},{"Id":392924,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"10135060190"},{"Id":392925,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"10135060290"},{"Id":392926,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"10135060301"},{"Id":392927,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"10135060310"},{"Id":392928,"FormularyType":"OHP","DrugName":"LAMIVUDINE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060002020","GenericName":"LAMIVUDINE ORAL SOLN 10 MG/ML","NDC":"10135060571"},{"Id":392929,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"10135060601"},{"Id":392930,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"10135060610"},{"Id":392931,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"10135060701"},{"Id":392932,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"10135060710"},{"Id":392933,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"10135060801"},{"Id":392934,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"10135060810"},{"Id":392935,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"10135060901"},{"Id":392936,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"10135060905"},{"Id":392937,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"10135061001"},{"Id":392938,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"10135061005"},{"Id":392939,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"10135061101"},{"Id":392940,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 500MG","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"10135061290"},{"Id":392941,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 750MG","DosageForm":"TBCR - Tablet ER","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000460","GenericName":"NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC)","NDC":"10135061390"},{"Id":392942,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"10135061490"},{"Id":392943,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"10135061530"},{"Id":392944,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"10135061630"},{"Id":392945,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"10135061710"},{"Id":392946,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"10135061805"},{"Id":392947,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"10135061905"},{"Id":392948,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100305","GenericName":"PHENAZOPYRIDINE HCL TAB 100 MG","NDC":"10135062001"},{"Id":392949,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100310","GenericName":"PHENAZOPYRIDINE HCL TAB 200 MG","NDC":"10135062101"},{"Id":392950,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"10135062902"},{"Id":392951,"FormularyType":"OHP","DrugName":"ACEBUTOLOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200010100105","GenericName":"ACEBUTOLOL HCL CAP 200 MG","NDC":"10135063001"},{"Id":392952,"FormularyType":"OHP","DrugName":"ACEBUTOLOL CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200010100110","GenericName":"ACEBUTOLOL HCL CAP 400 MG","NDC":"10135063101"},{"Id":392953,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"10135063205"},{"Id":392954,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"10135063301"},{"Id":392955,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"10135063305"},{"Id":392956,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"10135063401"},{"Id":392957,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"10135063405"},{"Id":392958,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"10135063501"},{"Id":392959,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"10135063505"},{"Id":392960,"FormularyType":"OHP","DrugName":"ACAMPRO CAL TAB 333MG","DosageForm":"TBEC - Tablet DR","Strength":"333","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802010200620","GenericName":"ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","NDC":"10135063632"},{"Id":392961,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"10135063701"},{"Id":392962,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"10135063705"},{"Id":392963,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"10135063801"},{"Id":392964,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"10135063810"},{"Id":392965,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"10135064001"},{"Id":392966,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"10135064005"},{"Id":392967,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"10135064010"},{"Id":392968,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"10135064101"},{"Id":392969,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"10135064201"},{"Id":392970,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"10135064301"},{"Id":392971,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"10135064401"},{"Id":392972,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"10135064405"},{"Id":392973,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"10135064501"},{"Id":392974,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"10135064505"},{"Id":392975,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"10135064601"},{"Id":392976,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"10135064605"},{"Id":392977,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"10135064701"},{"Id":392978,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"10135064705"},{"Id":392979,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"10135064801"},{"Id":392980,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"10135064805"},{"Id":392981,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"10135064910"},{"Id":392982,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"10135065005"},{"Id":392983,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"10135065110"},{"Id":392984,"FormularyType":"OHP","DrugName":"B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"10135065201"},{"Id":392985,"FormularyType":"OHP","DrugName":"B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"10135065250"},{"Id":392986,"FormularyType":"OHP","DrugName":"B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"10135065263"},{"Id":392987,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"10135065305"},{"Id":392988,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"10135065401"},{"Id":392989,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"10135065430"},{"Id":392990,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"10135065501"},{"Id":392991,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"10135065530"},{"Id":392992,"FormularyType":"OHP","DrugName":"SOTALOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"10135066101"},{"Id":392993,"FormularyType":"OHP","DrugName":"SOTALOL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"10135066201"},{"Id":392994,"FormularyType":"OHP","DrugName":"SOTALOL TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100320","GenericName":"SOTALOL HCL TAB 160 MG","NDC":"10135066301"},{"Id":392995,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"10135066401"},{"Id":392996,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"10135066501"},{"Id":392997,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"10135066601"},{"Id":392998,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"10135066610"},{"Id":392999,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"10135066701"},{"Id":393000,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"10135066710"},{"Id":393001,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"10135066801"},{"Id":393002,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"10135066869"},{"Id":393003,"FormularyType":"OHP","DrugName":"SENNA S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"10135066901"},{"Id":393004,"FormularyType":"OHP","DrugName":"FLUOCINOLONE SOL 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550055102005","GenericName":"FLUOCINOLONE ACETONIDE SOLN 0.01%","NDC":"10135067061"},{"Id":393005,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"10135067301"},{"Id":393006,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"10135067401"},{"Id":393007,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"10135067501"},{"Id":393008,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"10135067601"},{"Id":393009,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100337","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 3 MG","NDC":"10135067701"},{"Id":393010,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100344","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 4 MG","NDC":"10135067801"},{"Id":393011,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100350","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 5 MG","NDC":"10135067901"},{"Id":393012,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"10135068001"},{"Id":393013,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10135068304"},{"Id":393014,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10135068308"},{"Id":393015,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10135068312"},{"Id":393016,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"10135068510"},{"Id":393017,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"10135068601"},{"Id":393018,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"10135068701"},{"Id":393019,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"10135068801"},{"Id":393020,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135068962"},{"Id":393021,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"10135069001"},{"Id":393022,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"10135069161"},{"Id":393023,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"10135069201"},{"Id":393024,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"10135069205"},{"Id":393025,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"10135069301"},{"Id":393026,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"10135069305"},{"Id":393027,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"10135069508"},{"Id":393028,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"10135069612"},{"Id":393029,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"10135069644"},{"Id":393030,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"10135069712"},{"Id":393031,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"10135069720"},{"Id":393032,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"10135069744"},{"Id":393033,"FormularyType":"OHP","DrugName":"HYDROXYUREA CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700030000105","GenericName":"HYDROXYUREA CAP 500 MG","NDC":"10135070201"},{"Id":393034,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"10135070605"},{"Id":393035,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"10135070660"},{"Id":393036,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"10135070705"},{"Id":393037,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"10135070760"},{"Id":393038,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"10135070801"},{"Id":393039,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"10135070901"},{"Id":393040,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"10135070905"},{"Id":393041,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"10135071001"},{"Id":393042,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"10135071101"},{"Id":393043,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"10135071105"},{"Id":393044,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"10135071201"},{"Id":393045,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"10135071205"},{"Id":393046,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"10135071301"},{"Id":393047,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"10135071305"},{"Id":393048,"FormularyType":"OHP","DrugName":"FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"10135071492"},{"Id":393049,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120310","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 80 MG","NDC":"10135071501"},{"Id":393050,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120315","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 120 MG","NDC":"10135071601"},{"Id":393051,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120320","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 160 MG","NDC":"10135071701"},{"Id":393052,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"10135071812"},{"Id":393053,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"10135071844"},{"Id":393054,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"10135071912"},{"Id":393055,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"10135071944"},{"Id":393056,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"10135072085"},{"Id":393057,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"10135072201"},{"Id":393058,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"10135072205"},{"Id":393059,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"10135072301"},{"Id":393060,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"10135072305"},{"Id":393061,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135072910"},{"Id":393062,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10135072962"},{"Id":393063,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"10135073001"},{"Id":393064,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"10135073101"},{"Id":393065,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"10135073201"},{"Id":393066,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100310","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","NDC":"10135073301"},{"Id":393067,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100320","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","NDC":"10135073401"},{"Id":393068,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"10135073501"},{"Id":393069,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"10135073560"},{"Id":393070,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"10135073590"},{"Id":393071,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"10135073651"},{"Id":393072,"FormularyType":"OHP","DrugName":"SELEGILINE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100120","GenericName":"SELEGILINE HCL CAP 5 MG","NDC":"10135073760"},{"Id":393073,"FormularyType":"OHP","DrugName":"RIFABUTIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000075000120","GenericName":"RIFABUTIN CAP 150 MG","NDC":"10135073801"},{"Id":393074,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"10135074001"},{"Id":393075,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"10135074005"},{"Id":393076,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"10135074101"},{"Id":393077,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"10135074105"},{"Id":393078,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"10135074205"},{"Id":393079,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"10135074230"},{"Id":393080,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000305","GenericName":"PINDOLOL TAB 5 MG","NDC":"10135074301"},{"Id":393081,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000310","GenericName":"PINDOLOL TAB 10 MG","NDC":"10135074401"},{"Id":393082,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000310","GenericName":"MISOPROSTOL TAB 100 MCG","NDC":"10135074560"},{"Id":393083,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000310","GenericName":"MISOPROSTOL TAB 100 MCG","NDC":"10135074562"},{"Id":393084,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"10135074660"},{"Id":393085,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"10135074701"},{"Id":393086,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"10135074710"},{"Id":393087,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"10135074801"},{"Id":393088,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"10135074810"},{"Id":393089,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"10135074901"},{"Id":393090,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"10135074932"},{"Id":393091,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"10135075001"},{"Id":393092,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"10135075910"},{"Id":393093,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"10135075990"},{"Id":393094,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"10135076010"},{"Id":393095,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"10135076090"},{"Id":393096,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"10135076110"},{"Id":393097,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"10135076190"},{"Id":393098,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10135076201"},{"Id":393099,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10135076203"},{"Id":393100,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10135076205"},{"Id":393101,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10135076230"},{"Id":393102,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10135076290"},{"Id":393103,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10135076303"},{"Id":393104,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10135076330"},{"Id":393105,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10135076390"},{"Id":393106,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"10135076501"},{"Id":393107,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"10135076601"},{"Id":393108,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"10135076701"},{"Id":393109,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"10135076830"},{"Id":393110,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"10135076990"},{"Id":393111,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"10135077090"},{"Id":393112,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"10135077190"},{"Id":393113,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"10135077201"},{"Id":393114,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"10135077301"},{"Id":393115,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"10135077401"},{"Id":393116,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"10135077501"},{"Id":393117,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"10135077601"},{"Id":393118,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"10135077610"},{"Id":393119,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"10135077701"},{"Id":393120,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"10135077710"},{"Id":393121,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"10135077801"},{"Id":393122,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"10135077805"},{"Id":393123,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"10135077810"},{"Id":393124,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"10135077901"},{"Id":393125,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"10135078001"},{"Id":393126,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"10135078101"},{"Id":393127,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"10135078110"},{"Id":393128,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"10135078201"},{"Id":393129,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"10135078205"},{"Id":393130,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"10135078210"},{"Id":393131,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"10135078662"},{"Id":393132,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"10135078705"},{"Id":393133,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"10135078730"},{"Id":393134,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"10135078790"},{"Id":393135,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100305","GenericName":"ETHAMBUTOL HCL TAB 100 MG","NDC":"10135079601"},{"Id":393136,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100310","GenericName":"ETHAMBUTOL HCL TAB 400 MG","NDC":"10135079701"},{"Id":393137,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"10135079841"},{"Id":393138,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"10135079960"},{"Id":393139,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"10135080060"},{"Id":393140,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"10135080160"},{"Id":393141,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"10135080260"},{"Id":393142,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000305","GenericName":"ISONIAZID TAB 100 MG","NDC":"10135080401"},{"Id":393143,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"10135080501"},{"Id":393144,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"10135080530"},{"Id":393145,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"10135080601"},{"Id":393146,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"10135080856"},{"Id":393147,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"10135080956"},{"Id":393148,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"10135081001"},{"Id":393149,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"10135081010"},{"Id":393150,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"10135081101"},{"Id":393151,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"10135081110"},{"Id":393152,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"10135081201"},{"Id":393153,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"10135081210"},{"Id":393154,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"10135081301"},{"Id":393155,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"10135081310"},{"Id":393156,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"10135081401"},{"Id":393157,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"10135081410"},{"Id":393158,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"10135081501"},{"Id":393159,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"10135081510"},{"Id":393160,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082305"},{"Id":393161,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082330"},{"Id":393162,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082332"},{"Id":393163,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082333"},{"Id":393164,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082360"},{"Id":393165,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082362"},{"Id":393166,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"10135082390"},{"Id":393167,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"10135082405"},{"Id":393168,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"10135082490"},{"Id":393169,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10135082801"},{"Id":393170,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10135082901"},{"Id":393171,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"10135083001"},{"Id":393172,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"10135083101"},{"Id":393173,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"10135083201"},{"Id":393174,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"10135083210"},{"Id":393175,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"10135083290"},{"Id":393176,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"10135083301"},{"Id":393177,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"10135083310"},{"Id":393178,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"10135083390"},{"Id":393179,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"10135083401"},{"Id":393180,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"10135083405"},{"Id":393181,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000320","GenericName":"ETRAVIRINE TAB 100 MG","NDC":"10147057001"},{"Id":393182,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000340","GenericName":"ETRAVIRINE TAB 200 MG","NDC":"10147057101"},{"Id":393183,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"10147170003"},{"Id":393184,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"10267001201"},{"Id":393185,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"10267001204"},{"Id":393186,"FormularyType":"OHP","DrugName":"PSYLDEX POW 30%","DosageForm":"POWD - Powder","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102930","GenericName":"PSYLLIUM POWDER 30%","NDC":"10267040714"},{"Id":393187,"FormularyType":"OHP","DrugName":"PSYLDEX POW 30%","DosageForm":"POWD - Powder","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102930","GenericName":"PSYLLIUM POWDER 30%","NDC":"10267040721"},{"Id":393188,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10267083501"},{"Id":393189,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10267083504"},{"Id":393190,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"10267083601"},{"Id":393191,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"10267083604"},{"Id":393192,"FormularyType":"OHP","DrugName":"PSYLDEX POW 30%","DosageForm":"POWD - Powder","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102930","GenericName":"PSYLLIUM POWDER 30%","NDC":"10267085814"},{"Id":393193,"FormularyType":"OHP","DrugName":"PSYLDEX POW 30%","DosageForm":"POWD - Powder","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102930","GenericName":"PSYLLIUM POWDER 30%","NDC":"10267085821"},{"Id":393194,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"10267095001"},{"Id":393195,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"10267095004"},{"Id":393196,"FormularyType":"OHP","DrugName":"CO-NATAL FA TAB 29-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000332","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 29-1 MG***","NDC":"10267227001"},{"Id":393197,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10267240401"},{"Id":393198,"FormularyType":"OHP","DrugName":"TRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21708080000110","GenericName":"TRETINOIN CAP 10 MG","NDC":"10370026801"},{"Id":393199,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"10370082905"},{"Id":393200,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"10370082909"},{"Id":393201,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"10370082911"},{"Id":393202,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"10370083005"},{"Id":393203,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"10370083009"},{"Id":393204,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"10370083011"},{"Id":393205,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"10370083105"},{"Id":393206,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"10370083109"},{"Id":393207,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"10370083111"},{"Id":393208,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"10370083205"},{"Id":393209,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"10370083209"},{"Id":393210,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"10370083211"},{"Id":393211,"FormularyType":"OHP","DrugName":"KPN PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000303","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.1 MG***","NDC":"10432003301"},{"Id":393212,"FormularyType":"OHP","DrugName":"KPN PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000303","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.1 MG***","NDC":"10432003302"},{"Id":393213,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"10432003801"},{"Id":393214,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000310","GenericName":"NIACINAMIDE TAB 100 MG","NDC":"10432003901"},{"Id":393215,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100320","GenericName":"THIAMINE HCL TAB 50 MG","NDC":"10432008001"},{"Id":393216,"FormularyType":"OHP","DrugName":"VITAMIN B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"10432008101"},{"Id":393217,"FormularyType":"OHP","DrugName":"VITAMIN B 6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10432008701"},{"Id":393218,"FormularyType":"OHP","DrugName":"VITAMIN B 6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"10432008702"},{"Id":393219,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"10432008801"},{"Id":393220,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"10432008802"},{"Id":393221,"FormularyType":"OHP","DrugName":"PSYLLIUM SEE POW 100%","DosageForm":"POWD - Powder","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102999","GenericName":"PSYLLIUM POWDER 100%","NDC":"10432012203"},{"Id":393222,"FormularyType":"OHP","DrugName":"NIACIN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000320","GenericName":"NIACIN TAB 50 MG","NDC":"10432013301"},{"Id":393223,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"10432013401"},{"Id":393224,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"10432013402"},{"Id":393225,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"10432013403"},{"Id":393226,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"10432014701"},{"Id":393227,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"10432014702"},{"Id":393228,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"10432016301"},{"Id":393229,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"10432016303"},{"Id":393230,"FormularyType":"OHP","DrugName":"DELTA D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"10432017002"},{"Id":393231,"FormularyType":"OHP","DrugName":"DELTA D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"10432017003"},{"Id":393232,"FormularyType":"OHP","DrugName":"ULTRAMINO POW SOY PROT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"10432019403"},{"Id":393233,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"10432023701"},{"Id":393234,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"10432023703"},{"Id":393235,"FormularyType":"OHP","DrugName":"VITAMIN E TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000320","GenericName":"VITAMIN E TAB 400 UNIT","NDC":"10432024501"},{"Id":393236,"FormularyType":"OHP","DrugName":"PRENATAL FRM TAB A-FREE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512050000310","GenericName":"*PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB 9-0.267 MG***","NDC":"10432028301"},{"Id":393237,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"10432028401"},{"Id":393238,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"10432028402"},{"Id":393239,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"10432028403"},{"Id":393240,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"10432030201"},{"Id":393241,"FormularyType":"OHP","DrugName":"VITAMIN D2 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000305","GenericName":"ERGOCALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"10432031202"},{"Id":393242,"FormularyType":"OHP","DrugName":"PRENATAL ONE TAB DAILY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"10432031301"},{"Id":393243,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000303","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 6.75-0.2 MG***","NDC":"10432035001"},{"Id":393244,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000303","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 6.75-0.2 MG***","NDC":"10432035002"},{"Id":393245,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000303","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 6.75-0.2 MG***","NDC":"10432035003"},{"Id":393246,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 3000UNIT","DosageForm":"TABS - Tablet","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000344","GenericName":"CHOLECALCIFEROL TAB 75 MCG (3000 UNIT)","NDC":"10432036901"},{"Id":393247,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"10432037002"},{"Id":393248,"FormularyType":"OHP","DrugName":"GORMEL CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"10481300101"},{"Id":393249,"FormularyType":"OHP","DrugName":"GORMEL CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"10481300105"},{"Id":393250,"FormularyType":"OHP","DrugName":"GORMEL CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"10481300106"},{"Id":393251,"FormularyType":"OHP","DrugName":"GORMEL CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"10481300116"},{"Id":393252,"FormularyType":"OHP","DrugName":"GORDONS UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"10481300504"},{"Id":393253,"FormularyType":"OHP","DrugName":"DIALYVITE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000330","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 1 MG***","NDC":"10542001010"},{"Id":393254,"FormularyType":"OHP","DrugName":"DIALYVITE/ TAB ZINC","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78136000000330","GenericName":"*B-COMPLEX W/ C-ZN & FOLIC ACID TAB 1 MG***","NDC":"10542001210"},{"Id":393255,"FormularyType":"OHP","DrugName":"DIALYVITE TAB 800","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"10542007010"},{"Id":393256,"FormularyType":"OHP","DrugName":"DIALYVITE D CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"10542009090"},{"Id":393257,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 50000UNT","DosageForm":"TABS - Tablet","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000370","GenericName":"CHOLECALCIFEROL TAB 1.25 MG (50000 UNIT)","NDC":"10542010002"},{"Id":393258,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 50000UNT","DosageForm":"TABS - Tablet","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000370","GenericName":"CHOLECALCIFEROL TAB 1.25 MG (50000 UNIT)","NDC":"10542010008"},{"Id":393259,"FormularyType":"OHP","DrugName":"PEG-3350 SOL ELECTROL","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992005302130","GenericName":"PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM","NDC":"10572010001"},{"Id":393260,"FormularyType":"OHP","DrugName":"PEG-3350/KCL SOL /SODIUM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992004302120","GenericName":"PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM","NDC":"10572030201"},{"Id":393261,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100305","GenericName":"PROMETHAZINE HCL TAB 12.5 MG","NDC":"10702000201"},{"Id":393262,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"10702000301"},{"Id":393263,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"10702000310"},{"Id":393264,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"10702000350"},{"Id":393265,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100315","GenericName":"PROMETHAZINE HCL TAB 50 MG","NDC":"10702000401"},{"Id":393266,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"10702000601"},{"Id":393267,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"10702000610"},{"Id":393268,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"10702000650"},{"Id":393269,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000701"},{"Id":393270,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000703"},{"Id":393271,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000706"},{"Id":393272,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000709"},{"Id":393273,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000710"},{"Id":393274,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000718"},{"Id":393275,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000727"},{"Id":393276,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"10702000750"},{"Id":393277,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"10702000801"},{"Id":393278,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"10702000850"},{"Id":393279,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"10702000901"},{"Id":393280,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"10702000950"},{"Id":393281,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"10702001001"},{"Id":393282,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"10702001050"},{"Id":393283,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"10702001101"},{"Id":393284,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"10702001110"},{"Id":393285,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"10702001150"},{"Id":393286,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"10702001201"},{"Id":393287,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"10702001210"},{"Id":393288,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"10702001250"},{"Id":393289,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"10702001601"},{"Id":393290,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"10702001606"},{"Id":393291,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"10702001650"},{"Id":393292,"FormularyType":"OHP","DrugName":"CHLORPHENIR TAB 12MG CR","DosageForm":"TBCR - Tablet ER","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150410","GenericName":"CHLORPHENIRAMINE MALEATE TAB ER 12 MG","NDC":"10702001706"},{"Id":393293,"FormularyType":"OHP","DrugName":"CHLORPHENIR TAB 12MG CR","DosageForm":"TBCR - Tablet ER","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150410","GenericName":"CHLORPHENIRAMINE MALEATE TAB ER 12 MG","NDC":"10702001724"},{"Id":393294,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"10702001801"},{"Id":393295,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"10702001850"},{"Id":393296,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"10702003615"},{"Id":393297,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"10702003645"},{"Id":393298,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"10702005601"},{"Id":393299,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"10702005650"},{"Id":393300,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"10702005701"},{"Id":393301,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"10702005750"},{"Id":393302,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"10702006501"},{"Id":393303,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"10702006503"},{"Id":393304,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"10702006601"},{"Id":393305,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"10702006603"},{"Id":393306,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"10702006606"},{"Id":393307,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100403","GenericName":"METHYLPHENIDATE HCL TAB ER 10 MG","NDC":"10702007501"},{"Id":393308,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100403","GenericName":"METHYLPHENIDATE HCL TAB ER 10 MG","NDC":"10702007506"},{"Id":393309,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100405","GenericName":"METHYLPHENIDATE HCL TAB ER 20 MG","NDC":"10702007601"},{"Id":393310,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100405","GenericName":"METHYLPHENIDATE HCL TAB ER 20 MG","NDC":"10702007606"},{"Id":393311,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"10702010001"},{"Id":393312,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"10702010101"},{"Id":393313,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"10702010201"},{"Id":393314,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100320","GenericName":"DEXMETHYLPHENIDATE HCL TAB 2.5 MG","NDC":"10702010601"},{"Id":393315,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100330","GenericName":"DEXMETHYLPHENIDATE HCL TAB 5 MG","NDC":"10702010701"},{"Id":393316,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100340","GenericName":"DEXMETHYLPHENIDATE HCL TAB 10 MG","NDC":"10702010801"},{"Id":393317,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102020","GenericName":"METHYLPHENIDATE HCL SOLN 5 MG/5ML","NDC":"10702016350"},{"Id":393318,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102030","GenericName":"METHYLPHENIDATE HCL SOLN 10 MG/5ML","NDC":"10702016450"},{"Id":393319,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100310","GenericName":"DESMOPRESSIN ACETATE TAB 0.1 MG","NDC":"10702016901"},{"Id":393320,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100320","GenericName":"DESMOPRESSIN ACETATE TAB 0.2 MG","NDC":"10702017001"},{"Id":393321,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"10702018501"},{"Id":393322,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"10702018550"},{"Id":393323,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"10702018601"},{"Id":393324,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"10702018650"},{"Id":393325,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"10702018701"},{"Id":393326,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"10702018750"},{"Id":393327,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"10702018901"},{"Id":393328,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"10702018910"},{"Id":393329,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"10702018950"},{"Id":393330,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"10702019001"},{"Id":393331,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"10702019010"},{"Id":393332,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"10702019050"},{"Id":393333,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"10702019101"},{"Id":393334,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"10702019110"},{"Id":393335,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"10702019150"},{"Id":393336,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"10702020101"},{"Id":393337,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"10702020110"},{"Id":393338,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"10702020150"},{"Id":393339,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"10702022321"},{"Id":393340,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"10702023701"},{"Id":393341,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"10702027703"},{"Id":393342,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"10702027803"},{"Id":393343,"FormularyType":"OHP","DrugName":"MOVE ALONG TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"10758002001"},{"Id":393344,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 1 MCG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000110","GenericName":"PARICALCITOL CAP 1 MCG","NDC":"10888500102"},{"Id":393345,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 2 MCG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000120","GenericName":"PARICALCITOL CAP 2 MCG","NDC":"10888500202"},{"Id":393346,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939002333"},{"Id":393347,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"10939020933"},{"Id":393348,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"10939021444"},{"Id":393349,"FormularyType":"OHP","DrugName":"GAUZE SPONGE PAD 2X2 8PLY","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"10939022822"},{"Id":393350,"FormularyType":"OHP","DrugName":"SM ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"10939025933"},{"Id":393351,"FormularyType":"OHP","DrugName":"SM STERILE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"10939030444"},{"Id":393352,"FormularyType":"OHP","DrugName":"SM IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939035433"},{"Id":393353,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"10939079433"},{"Id":393354,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"10939086081"},{"Id":393355,"FormularyType":"OHP","DrugName":"FT ANTIFUNGA CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"10939095500"},{"Id":393356,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"10939095502"},{"Id":393357,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"10939095503"},{"Id":393358,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939095515"},{"Id":393359,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939095516"},{"Id":393360,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939095517"},{"Id":393361,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939095518"},{"Id":393362,"FormularyType":"OHP","DrugName":"FT ALLR RLF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"10939095519"},{"Id":393363,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"10939095520"},{"Id":393364,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"10939095521"},{"Id":393365,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"10939095522"},{"Id":393366,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"10939095528"},{"Id":393367,"FormularyType":"OHP","DrugName":"FT ALRGY RLF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10939095529"},{"Id":393368,"FormularyType":"OHP","DrugName":"FT ALRGY RLF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"10939095530"},{"Id":393369,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"10939095531"},{"Id":393370,"FormularyType":"OHP","DrugName":"FT NSL DECON TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"10939095532"},{"Id":393371,"FormularyType":"OHP","DrugName":"FT NSL DECON TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"10939095534"},{"Id":393372,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"10939095537"},{"Id":393373,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939095541"},{"Id":393374,"FormularyType":"OHP","DrugName":"FT 24 HOUR SPR 55MCG","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"10939095542"},{"Id":393375,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"10939095563"},{"Id":393376,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939095568"},{"Id":393377,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939095574"},{"Id":393378,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939095575"},{"Id":393379,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939095576"},{"Id":393380,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"10939095580"},{"Id":393381,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"10939095581"},{"Id":393382,"FormularyType":"OHP","DrugName":"FT ANTACID SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"10939095588"},{"Id":393383,"FormularyType":"OHP","DrugName":"FT ANTACID SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"10939095591"},{"Id":393384,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10939095595"},{"Id":393385,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10939095596"},{"Id":393386,"FormularyType":"OHP","DrugName":"FT SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"10939095597"},{"Id":393387,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"10939095599"},{"Id":393388,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"10939095600"},{"Id":393389,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"10939095601"},{"Id":393390,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"10939095602"},{"Id":393391,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"10939095603"},{"Id":393392,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"10939095604"},{"Id":393393,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"10939095605"},{"Id":393394,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"10939095608"},{"Id":393395,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"10939095610"},{"Id":393396,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"10939095611"},{"Id":393397,"FormularyType":"OHP","DrugName":"FT FIBER LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"10939095612"},{"Id":393398,"FormularyType":"OHP","DrugName":"FT FIBER POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"10939095616"},{"Id":393399,"FormularyType":"OHP","DrugName":"FT LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10939095620"},{"Id":393400,"FormularyType":"OHP","DrugName":"FT LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10939095621"},{"Id":393401,"FormularyType":"OHP","DrugName":"FT LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"10939095622"},{"Id":393402,"FormularyType":"OHP","DrugName":"FT MOTION TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"10939095623"},{"Id":393403,"FormularyType":"OHP","DrugName":"FT MOTION TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"10939095624"},{"Id":393404,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"10939095625"},{"Id":393405,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"10939095626"},{"Id":393406,"FormularyType":"OHP","DrugName":"FT MINERAL ENE","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010005110","GenericName":"MINERAL OIL ENEMA","NDC":"10939095627"},{"Id":393407,"FormularyType":"OHP","DrugName":"FT GNTLE LAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"10939095628"},{"Id":393408,"FormularyType":"OHP","DrugName":"FT STL SOFT TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"10939095631"},{"Id":393409,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10939095632"},{"Id":393410,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"10939095634"},{"Id":393411,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"10939095635"},{"Id":393412,"FormularyType":"OHP","DrugName":"FT SENNA LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"10939095636"},{"Id":393413,"FormularyType":"OHP","DrugName":"FT ACID REDU CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"10939095638"},{"Id":393414,"FormularyType":"OHP","DrugName":"FT ACID REDU CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"10939095639"},{"Id":393415,"FormularyType":"OHP","DrugName":"FT ACID REDU CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"10939095640"},{"Id":393416,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"10939095642"},{"Id":393417,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"10939095643"},{"Id":393418,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"10939095644"},{"Id":393419,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"10939095645"},{"Id":393420,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10939095656"},{"Id":393421,"FormularyType":"OHP","DrugName":"FT MINERAL OIL","DosageForm":"OIL - Oil","Strength":"99.9","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"10939095657"},{"Id":393422,"FormularyType":"OHP","DrugName":"FT MAG CITRA SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"10939095658"},{"Id":393423,"FormularyType":"OHP","DrugName":"FT MAG CITRA SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"10939095659"},{"Id":393424,"FormularyType":"OHP","DrugName":"FT NSL DECON TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"10939095661"},{"Id":393425,"FormularyType":"OHP","DrugName":"FT CHILDRENS CHW MULTI","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"10939095662"},{"Id":393426,"FormularyType":"OHP","DrugName":"FT CHILDRENS CHW MULTI","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"10939095663"},{"Id":393427,"FormularyType":"OHP","DrugName":"CALC+VIT D3 TAB 500-5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"10939095673"},{"Id":393428,"FormularyType":"OHP","DrugName":"FT CALC CITR TAB VIT D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"10939095676"},{"Id":393429,"FormularyType":"OHP","DrugName":"FT CAL CITR+ TAB VIT D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"10939095677"},{"Id":393430,"FormularyType":"OHP","DrugName":"FT CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"10939095682"},{"Id":393431,"FormularyType":"OHP","DrugName":"FT IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"10939095683"},{"Id":393432,"FormularyType":"OHP","DrugName":"FT IRON SLOW TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"10939095684"},{"Id":393433,"FormularyType":"OHP","DrugName":"FT MAGNES OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"241.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"10939095686"},{"Id":393434,"FormularyType":"OHP","DrugName":"FT CALC CITR TAB +VITA D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"10939095689"},{"Id":393435,"FormularyType":"OHP","DrugName":"FT PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"10939095708"},{"Id":393436,"FormularyType":"OHP","DrugName":"FT B-COMPLEX TAB + VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"10939095709"},{"Id":393437,"FormularyType":"OHP","DrugName":"FT VIT B-12 TAB MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"10939095710"},{"Id":393438,"FormularyType":"OHP","DrugName":"FT VIT B-12 TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"10939095711"},{"Id":393439,"FormularyType":"OHP","DrugName":"FT VIT B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"10939095714"},{"Id":393440,"FormularyType":"OHP","DrugName":"FT VIT D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"10939095715"},{"Id":393441,"FormularyType":"OHP","DrugName":"FT VIT D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"10939095716"},{"Id":393442,"FormularyType":"OHP","DrugName":"FT VIT B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"10939095717"},{"Id":393443,"FormularyType":"OHP","DrugName":"FT VIT D3 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"10939095723"},{"Id":393444,"FormularyType":"OHP","DrugName":"FT VITAMIN CAP D3 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"10939095724"},{"Id":393445,"FormularyType":"OHP","DrugName":"FT VITAMIN TAB D3 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"10939095725"},{"Id":393446,"FormularyType":"OHP","DrugName":"FT VITAMIN CAP D3 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"10939095726"},{"Id":393447,"FormularyType":"OHP","DrugName":"FT VIT D3 TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"10939095727"},{"Id":393448,"FormularyType":"OHP","DrugName":"FT FISH OIL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"10939095741"},{"Id":393449,"FormularyType":"OHP","DrugName":"FT FISH OIL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"10939095742"},{"Id":393450,"FormularyType":"OHP","DrugName":"FT FOLIC ACI TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"10939095744"},{"Id":393451,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"10939095745"},{"Id":393452,"FormularyType":"OHP","DrugName":"FT MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"10939095748"},{"Id":393453,"FormularyType":"OHP","DrugName":"FT MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"10939095749"},{"Id":393454,"FormularyType":"OHP","DrugName":"FT MELATONIN TAB 10MG","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000440","GenericName":"MELATONIN TAB ER 10 MG","NDC":"10939095750"},{"Id":393455,"FormularyType":"OHP","DrugName":"FT MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"10939095751"},{"Id":393456,"FormularyType":"OHP","DrugName":"FT MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"10939095752"},{"Id":393457,"FormularyType":"OHP","DrugName":"FT MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"10939095753"},{"Id":393458,"FormularyType":"OHP","DrugName":"FT POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"10939095755"},{"Id":393459,"FormularyType":"OHP","DrugName":"FT VIT D3 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"10939095761"},{"Id":393460,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"10939095765"},{"Id":393461,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"10939095766"},{"Id":393462,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"10939095767"},{"Id":393463,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"10939095768"},{"Id":393464,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"10939095769"},{"Id":393465,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"10939095770"},{"Id":393466,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095771"},{"Id":393467,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095774"},{"Id":393468,"FormularyType":"OHP","DrugName":"FT 8HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"10939095775"},{"Id":393469,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095776"},{"Id":393470,"FormularyType":"OHP","DrugName":"FT CHLD PAIN CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"10939095779"},{"Id":393471,"FormularyType":"OHP","DrugName":"FT NITE SLP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"10939095780"},{"Id":393472,"FormularyType":"OHP","DrugName":"FT SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"10939095781"},{"Id":393473,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"10939095783"},{"Id":393474,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095784"},{"Id":393475,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095785"},{"Id":393476,"FormularyType":"OHP","DrugName":"FT MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"10939095786"},{"Id":393477,"FormularyType":"OHP","DrugName":"FT ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"10939095787"},{"Id":393478,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095789"},{"Id":393479,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095790"},{"Id":393480,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095791"},{"Id":393481,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095792"},{"Id":393482,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095793"},{"Id":393483,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939095794"},{"Id":393484,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095797"},{"Id":393485,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095798"},{"Id":393486,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095799"},{"Id":393487,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939095800"},{"Id":393488,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"10939095803"},{"Id":393489,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"10939095804"},{"Id":393490,"FormularyType":"OHP","DrugName":"FT IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"10939095805"},{"Id":393491,"FormularyType":"OHP","DrugName":"IBUPROFEN IB CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"10939095806"},{"Id":393492,"FormularyType":"OHP","DrugName":"FT IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"10939095807"},{"Id":393493,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10939095811"},{"Id":393494,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10939095812"},{"Id":393495,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10939095813"},{"Id":393496,"FormularyType":"OHP","DrugName":"FT SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"10939095814"},{"Id":393497,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"10939095823"},{"Id":393498,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"10939095824"},{"Id":393499,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"10939095835"},{"Id":393500,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"10939095836"},{"Id":393501,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"10939095837"},{"Id":393502,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"10939095838"},{"Id":393503,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"10939095839"},{"Id":393504,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"10939095840"},{"Id":393505,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"10939095843"},{"Id":393506,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"10939095844"},{"Id":393507,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"10939095845"},{"Id":393508,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"10939095846"},{"Id":393509,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"10939095847"},{"Id":393510,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"10939095848"},{"Id":393511,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"10939095849"},{"Id":393512,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"10939095850"},{"Id":393513,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"10939095851"},{"Id":393514,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"10939095852"},{"Id":393515,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"10939095853"},{"Id":393516,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"10939095854"},{"Id":393517,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"10939095855"},{"Id":393518,"FormularyType":"OHP","DrugName":"FT GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"10939095867"},{"Id":393519,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"10939095892"},{"Id":393520,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"10939095899"},{"Id":393521,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"10939095902"},{"Id":393522,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"10939095903"},{"Id":393523,"FormularyType":"OHP","DrugName":"FT ELECTROLY SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"10939095905"},{"Id":393524,"FormularyType":"OHP","DrugName":"FT ELECTROLY SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"10939095906"},{"Id":393525,"FormularyType":"OHP","DrugName":"FT ELECTROLY SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"10939095907"},{"Id":393526,"FormularyType":"OHP","DrugName":"FT ADHESIVE PAD SHEER","DosageForm":"PADS - Pad","Strength":"0.1","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"10939095932"},{"Id":393527,"FormularyType":"OHP","DrugName":"FT ADHESIVE PAD SHEER","DosageForm":"PADS - Pad","Strength":"0.1","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"10939095934"},{"Id":393528,"FormularyType":"OHP","DrugName":"FT ANTIBIOTI OIN","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"10939095978"},{"Id":393529,"FormularyType":"OHP","DrugName":"FT ITCH RELF OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"10939095981"},{"Id":393530,"FormularyType":"OHP","DrugName":"FT ITCH RELF CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"10939095982"},{"Id":393531,"FormularyType":"OHP","DrugName":"FT ITCH RELF CRE /ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"10939095983"},{"Id":393532,"FormularyType":"OHP","DrugName":"FT ITCH RELF CRE /ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"10939095984"},{"Id":393533,"FormularyType":"OHP","DrugName":"FT TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"10939095985"},{"Id":393534,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"10939095987"},{"Id":393535,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"10939095992"},{"Id":393536,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"10939095995"},{"Id":393537,"FormularyType":"OHP","DrugName":"FT MICONAZ 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"10939095996"},{"Id":393538,"FormularyType":"OHP","DrugName":"FT CLOTRIMAZ CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"10939096002"},{"Id":393539,"FormularyType":"OHP","DrugName":"FT ALRGY CHD SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"10939096024"},{"Id":393540,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"10939096039"},{"Id":393541,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"10939096040"},{"Id":393542,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939096042"},{"Id":393543,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939096043"},{"Id":393544,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"10939096045"},{"Id":393545,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"10939096054"},{"Id":393546,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"10939096070"},{"Id":393547,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"10939096075"},{"Id":393548,"FormularyType":"OHP","DrugName":"FT 7 DAY VAG CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003705","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 1%","NDC":"10939096078"},{"Id":393549,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"10939096080"},{"Id":393550,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"10939096082"},{"Id":393551,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"10939096083"},{"Id":393552,"FormularyType":"OHP","DrugName":"FT ALRGY RLF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"10939096085"},{"Id":393553,"FormularyType":"OHP","DrugName":"FT ALRGY RLF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"10939096086"},{"Id":393554,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939096087"},{"Id":393555,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"10939096088"},{"Id":393556,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10939096090"},{"Id":393557,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10939096091"},{"Id":393558,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"10939096092"},{"Id":393559,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"10939096095"},{"Id":393560,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUP 650MG","DosageForm":"SUPP - Suppository","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005220","GenericName":"ACETAMINOPHEN SUPPOS 650 MG","NDC":"10939096096"},{"Id":393561,"FormularyType":"OHP","DrugName":"FT IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"10939096099"},{"Id":393562,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"10939096101"},{"Id":393563,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939096103"},{"Id":393564,"FormularyType":"OHP","DrugName":"FT AMMONIUM LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"10939096105"},{"Id":393565,"FormularyType":"OHP","DrugName":"FT AMMONIUM LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"10939096106"},{"Id":393566,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"10939096107"},{"Id":393567,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939096116"},{"Id":393568,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939096117"},{"Id":393569,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939096118"},{"Id":393570,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939096119"},{"Id":393571,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"10939096120"},{"Id":393572,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"10939096121"},{"Id":393573,"FormularyType":"OHP","DrugName":"FT NALOXONE SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"10939096123"},{"Id":393574,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"10939096131"},{"Id":393575,"FormularyType":"OHP","DrugName":"FT MOTION CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"10939096149"},{"Id":393576,"FormularyType":"OHP","DrugName":"FT ARTHRITIS GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"10939096165"},{"Id":393577,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"10939096216"},{"Id":393578,"FormularyType":"OHP","DrugName":"REESES MED SUS PINWORM","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"10956061801"},{"Id":393579,"FormularyType":"OHP","DrugName":"REESES MED SUS PINWORM","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"10956061821"},{"Id":393580,"FormularyType":"OHP","DrugName":"KERALYT GEL 3%","DosageForm":"GEL - Gel","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004080","GenericName":"SALICYLIC ACID GEL 3%","NDC":"11086003801"},{"Id":393581,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003001"},{"Id":393582,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003042"},{"Id":393583,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003044"},{"Id":393584,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003045"},{"Id":393585,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003048"},{"Id":393586,"FormularyType":"OHP","DrugName":"PEDI PEPTIDE LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003052"},{"Id":393587,"FormularyType":"OHP","DrugName":"PEDI PEPTIDE LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003053"},{"Id":393588,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003054"},{"Id":393589,"FormularyType":"OHP","DrugName":"RENAL SUPPRT LIQ 1.8","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003064"},{"Id":393590,"FormularyType":"OHP","DrugName":"RENAL SUPPRT LIQ 1.8","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003065"},{"Id":393591,"FormularyType":"OHP","DrugName":"GLUCOSE SUP LIQ 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003066"},{"Id":393592,"FormularyType":"OHP","DrugName":"GLUCOSE SUP LIQ 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003067"},{"Id":393593,"FormularyType":"OHP","DrugName":"PEDI STANDAR LIQ 1.2 CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003068"},{"Id":393594,"FormularyType":"OHP","DrugName":"PEDI PEPTIDE LIQ 1.5","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003069"},{"Id":393595,"FormularyType":"OHP","DrugName":"PEDI PEPTIDE LIQ 1.5","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003070"},{"Id":393596,"FormularyType":"OHP","DrugName":"PEDI STANDAR LIQ 1.2 CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003071"},{"Id":393597,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003080"},{"Id":393598,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003119"},{"Id":393599,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003121"},{"Id":393600,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003123"},{"Id":393601,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003131"},{"Id":393602,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003142"},{"Id":393603,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11112003148"},{"Id":393604,"FormularyType":"OHP","DrugName":"SCALPICIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075002005","GenericName":"HYDROCORTISONE SOLN 1%","NDC":"11509005400"},{"Id":393605,"FormularyType":"OHP","DrugName":"SODIUM FLUOR PST 5000 PPM","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"11527073044"},{"Id":393606,"FormularyType":"OHP","DrugName":"SODIUM FLUOR PST 5000 PPM","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"11527075043"},{"Id":393607,"FormularyType":"OHP","DrugName":"SODIUM FLUOR GEL 5000 PPM","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"11527075534"},{"Id":393608,"FormularyType":"OHP","DrugName":"SENNA/DSS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11534009001"},{"Id":393609,"FormularyType":"OHP","DrugName":"SENNA/DSS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11534009060"},{"Id":393610,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"11534016501"},{"Id":393611,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"11534016503"},{"Id":393612,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"11534016615"},{"Id":393613,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"11534016616"},{"Id":393614,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"11534016644"},{"Id":393615,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"11534016709"},{"Id":393616,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"11534016710"},{"Id":393617,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"11534016809"},{"Id":393618,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"11534016810"},{"Id":393619,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"11534016909"},{"Id":393620,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"11534016910"},{"Id":393621,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11534018019"},{"Id":393622,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11534018028"},{"Id":393623,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11534018050"},{"Id":393624,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"11534018801"},{"Id":393625,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"11534018901"},{"Id":393626,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"11534019001"},{"Id":393627,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"11534019101"},{"Id":393628,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"11534019201"},{"Id":393629,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"11534019301"},{"Id":393630,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"11534019401"},{"Id":393631,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"11534019501"},{"Id":393632,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"11534019601"},{"Id":393633,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"11534020001"},{"Id":393634,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"11534020004"},{"Id":393635,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"11534020007"},{"Id":393636,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"11534020401"},{"Id":393637,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"11534020403"},{"Id":393638,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"11534020404"},{"Id":393639,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"11534020501"},{"Id":393640,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"11534020503"},{"Id":393641,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"11534020504"},{"Id":393642,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"11534020601"},{"Id":393643,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"11534020603"},{"Id":393644,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"11534020604"},{"Id":393645,"FormularyType":"OHP","DrugName":"BAZA ANTIFUN CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"11701004514"},{"Id":393646,"FormularyType":"OHP","DrugName":"BAZA ANTIFUN CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"11701004523"},{"Id":393647,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"11788000801"},{"Id":393648,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"11788000805"},{"Id":393649,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"11788000901"},{"Id":393650,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"11788000905"},{"Id":393651,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"11788001001"},{"Id":393652,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"11788001005"},{"Id":393653,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"11788004601"},{"Id":393654,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"11788004605"},{"Id":393655,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"11788004610"},{"Id":393656,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"11788004701"},{"Id":393657,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"11788004705"},{"Id":393658,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"11788004710"},{"Id":393659,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"11788005101"},{"Id":393660,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"11788005201"},{"Id":393661,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100320","GenericName":"SOTALOL HCL TAB 160 MG","NDC":"11788005301"},{"Id":393662,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100330","GenericName":"SOTALOL HCL TAB 240 MG","NDC":"11788005401"},{"Id":393663,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"11788010010"},{"Id":393664,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"11788010030"},{"Id":393665,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"11788010090"},{"Id":393666,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"11788010110"},{"Id":393667,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"11788010130"},{"Id":393668,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"11788010190"},{"Id":393669,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"11788010210"},{"Id":393670,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"11788010230"},{"Id":393671,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"11788010290"},{"Id":393672,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"11788011301"},{"Id":393673,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"11788011305"},{"Id":393674,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"11788011401"},{"Id":393675,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"11788011405"},{"Id":393676,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"11788011607"},{"Id":393677,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"11788012813"},{"Id":393678,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"11788012913"},{"Id":393679,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"11788012914"},{"Id":393680,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"11788012915"},{"Id":393681,"FormularyType":"OHP","DrugName":"E 1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"11845005041"},{"Id":393682,"FormularyType":"OHP","DrugName":"E 1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"11845005049"},{"Id":393683,"FormularyType":"OHP","DrugName":"B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"11845005651"},{"Id":393684,"FormularyType":"OHP","DrugName":"B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"11845005701"},{"Id":393685,"FormularyType":"OHP","DrugName":"B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11845005711"},{"Id":393686,"FormularyType":"OHP","DrugName":"B-12 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000310","GenericName":"CYANOCOBALAMIN TAB 50 MCG","NDC":"11845005731"},{"Id":393687,"FormularyType":"OHP","DrugName":"B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"11845005741"},{"Id":393688,"FormularyType":"OHP","DrugName":"B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"11845005751"},{"Id":393689,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11845005761"},{"Id":393690,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"11845006181"},{"Id":393691,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"11845006531"},{"Id":393692,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"11845006761"},{"Id":393693,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"11845006935"},{"Id":393694,"FormularyType":"OHP","DrugName":"OYS SHELL CA TAB /VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11845007551"},{"Id":393695,"FormularyType":"OHP","DrugName":"OYS SHELL CA TAB /D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11845007552"},{"Id":393696,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB /VIT D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11845007555"},{"Id":393697,"FormularyType":"OHP","DrugName":"B-12 TAB 2000MCG","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000335","GenericName":"CYANOCOBALAMIN TAB 2000 MCG","NDC":"11845007625"},{"Id":393698,"FormularyType":"OHP","DrugName":"B-12 SR TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11845008051"},{"Id":393699,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 CR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11845008055"},{"Id":393700,"FormularyType":"OHP","DrugName":"SUPER CALCIU TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"11845008531"},{"Id":393701,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"11845009151"},{"Id":393702,"FormularyType":"OHP","DrugName":"LITTLE CHW ANIMALS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"11845009185"},{"Id":393703,"FormularyType":"OHP","DrugName":"B-12 SUB 1000MCG","DosageForm":"SUBL - Tab Sublingual","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000705","GenericName":"CYANOCOBALAMIN SL TAB 1000 MCG","NDC":"11845009661"},{"Id":393704,"FormularyType":"OHP","DrugName":"B-12 SUB 1000MCG","DosageForm":"SUBL - Tab Sublingual","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000705","GenericName":"CYANOCOBALAMIN SL TAB 1000 MCG","NDC":"11845009662"},{"Id":393705,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"11845011831"},{"Id":393706,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11845012230"},{"Id":393707,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11845012232"},{"Id":393708,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11845012235"},{"Id":393709,"FormularyType":"OHP","DrugName":"CA CIT/VIT D TAB 315/200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"11845012375"},{"Id":393710,"FormularyType":"OHP","DrugName":"LIQ CA/VIT D CAP 600MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630150","GenericName":"CALCIUM CARBONATE-VITAMIN D CAP 600 MG-5 MCG (200 UNIT)","NDC":"11845012385"},{"Id":393711,"FormularyType":"OHP","DrugName":"MASONATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11845012791"},{"Id":393712,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"11845013751"},{"Id":393713,"FormularyType":"OHP","DrugName":"CALCIUM 600 CHW W/VIT D","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640550","GenericName":"CALCIUM CARB-CHOLECALCIF CHEW TAB 600 MG-10 MCG (400 UNIT)","NDC":"11845014031"},{"Id":393714,"FormularyType":"OHP","DrugName":"FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"11845014479"},{"Id":393715,"FormularyType":"OHP","DrugName":"SUPER OMEGA CAP -3","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11845014638"},{"Id":393716,"FormularyType":"OHP","DrugName":"D 1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11845014770"},{"Id":393717,"FormularyType":"OHP","DrugName":"D 1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11845014772"},{"Id":393718,"FormularyType":"OHP","DrugName":"D 1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11845014775"},{"Id":393719,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11845014922"},{"Id":393720,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11845014951"},{"Id":393721,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11845014971"},{"Id":393722,"FormularyType":"OHP","DrugName":"D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11845015010"},{"Id":393723,"FormularyType":"OHP","DrugName":"D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11845015012"},{"Id":393724,"FormularyType":"OHP","DrugName":"D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11845015015"},{"Id":393725,"FormularyType":"OHP","DrugName":"D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11845015331"},{"Id":393726,"FormularyType":"OHP","DrugName":"D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11845015339"},{"Id":393727,"FormularyType":"OHP","DrugName":"VITAMIN D CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"11845015469"},{"Id":393728,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"11845016011"},{"Id":393729,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"11845016235"},{"Id":393730,"FormularyType":"OHP","DrugName":"D3 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"11845016238"},{"Id":393731,"FormularyType":"OHP","DrugName":"BINAXNOW COV KIT HOME TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"11877001133"},{"Id":393732,"FormularyType":"OHP","DrugName":"BINAXNOW COV KIT HOME TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"11877001140"},{"Id":393733,"FormularyType":"OHP","DrugName":"BINAXNOW KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"11877001172"},{"Id":393734,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917000365"},{"Id":393735,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"11917000540"},{"Id":393736,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"11917000555"},{"Id":393737,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917000576"},{"Id":393738,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917000578"},{"Id":393739,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917000591"},{"Id":393740,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917000592"},{"Id":393741,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917000693"},{"Id":393742,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11917000735"},{"Id":393743,"FormularyType":"OHP","DrugName":"ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917000803"},{"Id":393744,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917000921"},{"Id":393745,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917000928"},{"Id":393746,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917000929"},{"Id":393747,"FormularyType":"OHP","DrugName":"GLYCERIN PED SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"11917001005"},{"Id":393748,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"11917001006"},{"Id":393749,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"11917001008"},{"Id":393750,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"11917001009"},{"Id":393751,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"11917001052"},{"Id":393752,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"11917001146"},{"Id":393753,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917001164"},{"Id":393754,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917001170"},{"Id":393755,"FormularyType":"OHP","DrugName":"NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917001338"},{"Id":393756,"FormularyType":"OHP","DrugName":"NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917001339"},{"Id":393757,"FormularyType":"OHP","DrugName":"NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917001343"},{"Id":393758,"FormularyType":"OHP","DrugName":"NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917001394"},{"Id":393759,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917001407"},{"Id":393760,"FormularyType":"OHP","DrugName":"WAL-PROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917001414"},{"Id":393761,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917001431"},{"Id":393762,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917001440"},{"Id":393763,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"11917001487"},{"Id":393764,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"11917001489"},{"Id":393765,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"11917001492"},{"Id":393766,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"11917001501"},{"Id":393767,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"11917001520"},{"Id":393768,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"11917001521"},{"Id":393769,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"11917002072"},{"Id":393770,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"11917002103"},{"Id":393771,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11917002191"},{"Id":393772,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917002236"},{"Id":393773,"FormularyType":"OHP","DrugName":"LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"11917002266"},{"Id":393774,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917002362"},{"Id":393775,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"11917002527"},{"Id":393776,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"11917002528"},{"Id":393777,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"11917002529"},{"Id":393778,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"11917002532"},{"Id":393779,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"11917002536"},{"Id":393780,"FormularyType":"OHP","DrugName":"EASY-LAX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"11917002600"},{"Id":393781,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"11917002603"},{"Id":393782,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917002613"},{"Id":393783,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL BUBBLGUM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917002615"},{"Id":393784,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL UNFLAVRD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917002710"},{"Id":393785,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"11917002741"},{"Id":393786,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917002761"},{"Id":393787,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917002801"},{"Id":393788,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917003175"},{"Id":393789,"FormularyType":"OHP","DrugName":"NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917003194"},{"Id":393790,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917003515"},{"Id":393791,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"11917003564"},{"Id":393792,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"11917003586"},{"Id":393793,"FormularyType":"OHP","DrugName":"B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917003587"},{"Id":393794,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"11917003776"},{"Id":393795,"FormularyType":"OHP","DrugName":"STERILE GAUZ PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"11917003813"},{"Id":393796,"FormularyType":"OHP","DrugName":"LAND BFR TIM CHW VIT/C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"11917003886"},{"Id":393797,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"11917003897"},{"Id":393798,"FormularyType":"OHP","DrugName":"SUPER B COMP TAB VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"11917003899"},{"Id":393799,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"11917003916"},{"Id":393800,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"11917003920"},{"Id":393801,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"11917003925"},{"Id":393802,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917003926"},{"Id":393803,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000310","GenericName":"CYANOCOBALAMIN TAB 50 MCG","NDC":"11917003928"},{"Id":393804,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"11917003929"},{"Id":393805,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"11917003930"},{"Id":393806,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917003939"},{"Id":393807,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917003940"},{"Id":393808,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917003941"},{"Id":393809,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"11917003947"},{"Id":393810,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"11917003949"},{"Id":393811,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"11917003960"},{"Id":393812,"FormularyType":"OHP","DrugName":"FISH OIL CON CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"11917003961"},{"Id":393813,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"11917004033"},{"Id":393814,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917004049"},{"Id":393815,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"11917004068"},{"Id":393816,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"11917004074"},{"Id":393817,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"11917004075"},{"Id":393818,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 160MG JR","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"11917004076"},{"Id":393819,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 160MG JR","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"11917004077"},{"Id":393820,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917004129"},{"Id":393821,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"11917004161"},{"Id":393822,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"11917004169"},{"Id":393823,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"11917004231"},{"Id":393824,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917004295"},{"Id":393825,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917004296"},{"Id":393826,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917004304"},{"Id":393827,"FormularyType":"OHP","DrugName":"WAL-FINATE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"11917004384"},{"Id":393828,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917004402"},{"Id":393829,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917004403"},{"Id":393830,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917004406"},{"Id":393831,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917004416"},{"Id":393832,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"11917004459"},{"Id":393833,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"11917004460"},{"Id":393834,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917004523"},{"Id":393835,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917004548"},{"Id":393836,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"11917004634"},{"Id":393837,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917004637"},{"Id":393838,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000145","GenericName":"VITAMIN E CAP 1000 UNIT","NDC":"11917004644"},{"Id":393839,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917004647"},{"Id":393840,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917004650"},{"Id":393841,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 200UNIT","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000130","GenericName":"VITAMIN E CAP 200 UNIT","NDC":"11917004651"},{"Id":393842,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917004681"},{"Id":393843,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917004682"},{"Id":393844,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"11917004724"},{"Id":393845,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"11917004725"},{"Id":393846,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"11917004726"},{"Id":393847,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917004776"},{"Id":393848,"FormularyType":"OHP","DrugName":"CALCIUM FOR CHW WOMEN","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903400530","GenericName":"CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-100 UNIT-40 MCG","NDC":"11917004801"},{"Id":393849,"FormularyType":"OHP","DrugName":"CALCIUM FOR CHW WOMEN","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903400530","GenericName":"CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-100 UNIT-40 MCG","NDC":"11917004802"},{"Id":393850,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"11917004813"},{"Id":393851,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"11917004814"},{"Id":393852,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"11917004815"},{"Id":393853,"FormularyType":"OHP","DrugName":"WAL-PROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917004917"},{"Id":393854,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917004918"},{"Id":393855,"FormularyType":"OHP","DrugName":"MENSTRUAL TAB MAX ST","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"11917004940"},{"Id":393856,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917004943"},{"Id":393857,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"11917004953"},{"Id":393858,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"11917004954"},{"Id":393859,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 0.5%","DosageForm":"OINT - Ointment","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004205","GenericName":"HYDROCORTISONE OINT 0.5%","NDC":"11917004955"},{"Id":393860,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% PLUS","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917004956"},{"Id":393861,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"11917004957"},{"Id":393862,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917004958"},{"Id":393863,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917004994"},{"Id":393864,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917004995"},{"Id":393865,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917005003"},{"Id":393866,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917005004"},{"Id":393867,"FormularyType":"OHP","DrugName":"CALCIUM CIT TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000310","GenericName":"CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA)","NDC":"11917005014"},{"Id":393868,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"11917005015"},{"Id":393869,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"11917005016"},{"Id":393870,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB + MIN","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450340","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-200 UNIT***","NDC":"11917005017"},{"Id":393871,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB + MIN","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450340","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-200 UNIT***","NDC":"11917005018"},{"Id":393872,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500/D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917005019"},{"Id":393873,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500/D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917005020"},{"Id":393874,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"11917005021"},{"Id":393875,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500/D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917005022"},{"Id":393876,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630365","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 600 MG-5 MCG (200 UNIT)","NDC":"11917005024"},{"Id":393877,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"11917005025"},{"Id":393878,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"11917005026"},{"Id":393879,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"1500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"11917005028"},{"Id":393880,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"11917005034"},{"Id":393881,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640333","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-3.125 MCG (125 UNIT)","NDC":"11917005035"},{"Id":393882,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB /VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640333","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-3.125 MCG (125 UNIT)","NDC":"11917005036"},{"Id":393883,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640333","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-3.125 MCG (125 UNIT)","NDC":"11917005037"},{"Id":393884,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"11917005039"},{"Id":393885,"FormularyType":"OHP","DrugName":"FIRST AID OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917005092"},{"Id":393886,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917005095"},{"Id":393887,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"11917005098"},{"Id":393888,"FormularyType":"OHP","DrugName":"ADHESIVE PAD 3\"X4\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"11917005113"},{"Id":393889,"FormularyType":"OHP","DrugName":"STRESS FORM TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917005126"},{"Id":393890,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917005131"},{"Id":393891,"FormularyType":"OHP","DrugName":"ANTACID M SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917005133"},{"Id":393892,"FormularyType":"OHP","DrugName":"ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917005138"},{"Id":393893,"FormularyType":"OHP","DrugName":"DISPOSABLE ENE SINGLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917005140"},{"Id":393894,"FormularyType":"OHP","DrugName":"FISH OIL CAP 435MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000142","GenericName":"*OMEGA-3 FATTY ACIDS CAP 435 MG**","NDC":"11917005207"},{"Id":393895,"FormularyType":"OHP","DrugName":"GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"11917005254"},{"Id":393896,"FormularyType":"OHP","DrugName":"TABLET CUTTR MIS /SAFETY","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97700000000000","GenericName":"*MISC. DEVICES**","NDC":"11917005315"},{"Id":393897,"FormularyType":"OHP","DrugName":"EASY-LAX PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917005318"},{"Id":393898,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917005319"},{"Id":393899,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917005356"},{"Id":393900,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917005357"},{"Id":393901,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917005358"},{"Id":393902,"FormularyType":"OHP","DrugName":"WAL-DRYL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"11917005392"},{"Id":393903,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"11917005393"},{"Id":393904,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917005426"},{"Id":393905,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917005427"},{"Id":393906,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917005444"},{"Id":393907,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917005445"},{"Id":393908,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917005446"},{"Id":393909,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917005490"},{"Id":393910,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917005491"},{"Id":393911,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917005505"},{"Id":393912,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917005506"},{"Id":393913,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL UNFLAVRD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917005507"},{"Id":393914,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917005508"},{"Id":393915,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL BUBBLGUM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917005509"},{"Id":393916,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FREEZE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917005510"},{"Id":393917,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917005516"},{"Id":393918,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917005517"},{"Id":393919,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG REF","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917005540"},{"Id":393920,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917005585"},{"Id":393921,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917005586"},{"Id":393922,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"11917005642"},{"Id":393923,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"11917005654"},{"Id":393924,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"11917005655"},{"Id":393925,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"11917005660"},{"Id":393926,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"11917005667"},{"Id":393927,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917005670"},{"Id":393928,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"11917005691"},{"Id":393929,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"11917005749"},{"Id":393930,"FormularyType":"OHP","DrugName":"PEDIATRIC LIQ DRINK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917005805"},{"Id":393931,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"11917005831"},{"Id":393932,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917005880"},{"Id":393933,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917005881"},{"Id":393934,"FormularyType":"OHP","DrugName":"FISH OIL CAP 435MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000142","GenericName":"*OMEGA-3 FATTY ACIDS CAP 435 MG**","NDC":"11917005895"},{"Id":393935,"FormularyType":"OHP","DrugName":"FISH OIL CON CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917005897"},{"Id":393936,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"11917005915"},{"Id":393937,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"11917006018"},{"Id":393938,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917006084"},{"Id":393939,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917006085"},{"Id":393940,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917006086"},{"Id":393941,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917006104"},{"Id":393942,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917006227"},{"Id":393943,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917006231"},{"Id":393944,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917006260"},{"Id":393945,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"11917006298"},{"Id":393946,"FormularyType":"OHP","DrugName":"ADHESIVE PAD 2\"X3\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"11917006302"},{"Id":393947,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"11917006307"},{"Id":393948,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"11917006343"},{"Id":393949,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"11917006436"},{"Id":393950,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917006439"},{"Id":393951,"FormularyType":"OHP","DrugName":"ANTACID LIQ SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917006440"},{"Id":393952,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917006441"},{"Id":393953,"FormularyType":"OHP","DrugName":"ANTACID M SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917006443"},{"Id":393954,"FormularyType":"OHP","DrugName":"TABLET CUTTR MIS /CRUSHER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97700000000000","GenericName":"*MISC. DEVICES**","NDC":"11917006446"},{"Id":393955,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"11917006483"},{"Id":393956,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917006512"},{"Id":393957,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917006544"},{"Id":393958,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917006545"},{"Id":393959,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917006546"},{"Id":393960,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917006547"},{"Id":393961,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917006548"},{"Id":393962,"FormularyType":"OHP","DrugName":"HYDROCORT/ CRE ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917006655"},{"Id":393963,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917006705"},{"Id":393964,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917006707"},{"Id":393965,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917006708"},{"Id":393966,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917006709"},{"Id":393967,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG STRT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917006719"},{"Id":393968,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG STRT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917006720"},{"Id":393969,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG STRT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917006721"},{"Id":393970,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG STRT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917006722"},{"Id":393971,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG REF","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917006724"},{"Id":393972,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG REF","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917006725"},{"Id":393973,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG REF","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917006727"},{"Id":393974,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG REF","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917006728"},{"Id":393975,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG REF","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917006729"},{"Id":393976,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917006772"},{"Id":393977,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917006773"},{"Id":393978,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"11917006799"},{"Id":393979,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917006843"},{"Id":393980,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917006844"},{"Id":393981,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917006845"},{"Id":393982,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"11917006914"},{"Id":393983,"FormularyType":"OHP","DrugName":"CAPSAICIN HP CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"11917006938"},{"Id":393984,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917006941"},{"Id":393985,"FormularyType":"OHP","DrugName":"MOTION SICK CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"11917007007"},{"Id":393986,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917007088"},{"Id":393987,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917007135"},{"Id":393988,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"11917007147"},{"Id":393989,"FormularyType":"OHP","DrugName":"FISH OIL CON CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917007157"},{"Id":393990,"FormularyType":"OHP","DrugName":"FISH OIL CAP 435MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000142","GenericName":"*OMEGA-3 FATTY ACIDS CAP 435 MG**","NDC":"11917007158"},{"Id":393991,"FormularyType":"OHP","DrugName":"WAL-VERT TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"11917007177"},{"Id":393992,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"11917007188"},{"Id":393993,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"11917007192"},{"Id":393994,"FormularyType":"OHP","DrugName":"WAL-DRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"11917007194"},{"Id":393995,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"11917007209"},{"Id":393996,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"11917007373"},{"Id":393997,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917007388"},{"Id":393998,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917007404"},{"Id":393999,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"11917007422"},{"Id":394000,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"11917007454"},{"Id":394001,"FormularyType":"OHP","DrugName":"VIT E D-ALPH CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000144","GenericName":"VITAMIN E CAP 670 MG (1000 UNIT)","NDC":"11917007462"},{"Id":394002,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917007463"},{"Id":394003,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"11917007472"},{"Id":394004,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917007489"},{"Id":394005,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"11917007492"},{"Id":394006,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640333","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-3.125 MCG (125 UNIT)","NDC":"11917007497"},{"Id":394007,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500+D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917007499"},{"Id":394008,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"11917007506"},{"Id":394009,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"11917007508"},{"Id":394010,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917007512"},{"Id":394011,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917007514"},{"Id":394012,"FormularyType":"OHP","DrugName":"CALCIUM CIT TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000310","GenericName":"CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA)","NDC":"11917007538"},{"Id":394013,"FormularyType":"OHP","DrugName":"CA CITRATE TAB + D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"11917007539"},{"Id":394014,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D/MNRLS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450350","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-400 UNIT***","NDC":"11917007541"},{"Id":394015,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D/MNRLS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450350","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-400 UNIT***","NDC":"11917007542"},{"Id":394016,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11917007546"},{"Id":394017,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917007548"},{"Id":394018,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917007550"},{"Id":394019,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917007559"},{"Id":394020,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917007568"},{"Id":394021,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917007569"},{"Id":394022,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917007573"},{"Id":394023,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917007574"},{"Id":394024,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917007575"},{"Id":394025,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"11917007592"},{"Id":394026,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"11917007602"},{"Id":394027,"FormularyType":"OHP","DrugName":"CHILDRENS CHW SOOTHE","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000504","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG","NDC":"11917007604"},{"Id":394028,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917007630"},{"Id":394029,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917007640"},{"Id":394030,"FormularyType":"OHP","DrugName":"MINERAL OIL ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010005110","GenericName":"MINERAL OIL ENEMA","NDC":"11917007645"},{"Id":394031,"FormularyType":"OHP","DrugName":"ANTACID MAX CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"11917007653"},{"Id":394032,"FormularyType":"OHP","DrugName":"WAL-MUCIL CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"11917007658"},{"Id":394033,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"11917007672"},{"Id":394034,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917007691"},{"Id":394035,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917007693"},{"Id":394036,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917007694"},{"Id":394037,"FormularyType":"OHP","DrugName":"PRENATAL TAB COMPLETE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000306","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 14-0.4 MG***","NDC":"11917007696"},{"Id":394038,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"11917007749"},{"Id":394039,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"11917007766"},{"Id":394040,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"11917007772"},{"Id":394041,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"11917007847"},{"Id":394042,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"11917007873"},{"Id":394043,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"11917007874"},{"Id":394044,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 100%","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102999","GenericName":"PSYLLIUM POWDER 100%","NDC":"11917007885"},{"Id":394045,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917007889"},{"Id":394046,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917007892"},{"Id":394047,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917007893"},{"Id":394048,"FormularyType":"OHP","DrugName":"B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917007926"},{"Id":394049,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"11917007928"},{"Id":394050,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917007929"},{"Id":394051,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917007930"},{"Id":394052,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917007931"},{"Id":394053,"FormularyType":"OHP","DrugName":"B-12 TR TAB 1000 MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917007932"},{"Id":394054,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917007933"},{"Id":394055,"FormularyType":"OHP","DrugName":"B-COMPLEX TAB BALANCED","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917007941"},{"Id":394056,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"11917007952"},{"Id":394057,"FormularyType":"OHP","DrugName":"B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917007957"},{"Id":394058,"FormularyType":"OHP","DrugName":"ASPIRIN CHLD CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"11917007961"},{"Id":394059,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917007966"},{"Id":394060,"FormularyType":"OHP","DrugName":"ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"11917007967"},{"Id":394061,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"11917007968"},{"Id":394062,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917007969"},{"Id":394063,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917007970"},{"Id":394064,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917007971"},{"Id":394065,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917007972"},{"Id":394066,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"11917007975"},{"Id":394067,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917008018"},{"Id":394068,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917008019"},{"Id":394069,"FormularyType":"OHP","DrugName":"WAL-PHED TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"11917008081"},{"Id":394070,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"11917008099"},{"Id":394071,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"11917008124"},{"Id":394072,"FormularyType":"OHP","DrugName":"WAL-MUCIL CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"11917008151"},{"Id":394073,"FormularyType":"OHP","DrugName":"FIBER-LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"11917008163"},{"Id":394074,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917008186"},{"Id":394075,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917008216"},{"Id":394076,"FormularyType":"OHP","DrugName":"WAL-ITIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"11917008262"},{"Id":394077,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL MANGO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917008421"},{"Id":394078,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917008502"},{"Id":394079,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917008513"},{"Id":394080,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917008527"},{"Id":394081,"FormularyType":"OHP","DrugName":"PEDIATRIC LIQ DRINK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917008531"},{"Id":394082,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917008608"},{"Id":394083,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"11917008613"},{"Id":394084,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917008707"},{"Id":394085,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"11917008767"},{"Id":394086,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917008778"},{"Id":394087,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"11917008799"},{"Id":394088,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917008809"},{"Id":394089,"FormularyType":"OHP","DrugName":"WAL-ITIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"11917008816"},{"Id":394090,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917008830"},{"Id":394091,"FormularyType":"OHP","DrugName":"OMEGA 3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917008863"},{"Id":394092,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917008917"},{"Id":394093,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"11917008946"},{"Id":394094,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"11917008947"},{"Id":394095,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"11917008959"},{"Id":394096,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917008983"},{"Id":394097,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917009012"},{"Id":394098,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"11917009061"},{"Id":394099,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"11917009088"},{"Id":394100,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917009126"},{"Id":394101,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917009215"},{"Id":394102,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917009216"},{"Id":394103,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917009241"},{"Id":394104,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917009245"},{"Id":394105,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917009246"},{"Id":394106,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917009247"},{"Id":394107,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917009248"},{"Id":394108,"FormularyType":"OHP","DrugName":"PRENATAL+DHA MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006318","GenericName":"*PRENATAL W/FE FUM-FA TAB 28-0.975 MG & DHA CAP 200 MG PACK*","NDC":"11917009311"},{"Id":394109,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"11917009374"},{"Id":394110,"FormularyType":"OHP","DrugName":"ASPIRIN-81 CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"11917009499"},{"Id":394111,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"11917009500"},{"Id":394112,"FormularyType":"OHP","DrugName":"CREAMIES CHW 600-400","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640550","GenericName":"CALCIUM CARB-CHOLECALCIF CHEW TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917009522"},{"Id":394113,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"11917009588"},{"Id":394114,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"11917009741"},{"Id":394115,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917009752"},{"Id":394116,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917009753"},{"Id":394117,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"11917009777"},{"Id":394118,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917009905"},{"Id":394119,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917010009"},{"Id":394120,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ STRWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917010010"},{"Id":394121,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917010012"},{"Id":394122,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ STRWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917010013"},{"Id":394123,"FormularyType":"OHP","DrugName":"NUTR DRINK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917010014"},{"Id":394124,"FormularyType":"OHP","DrugName":"CHEW CALCIUM CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903400535","GenericName":"CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG","NDC":"11917010163"},{"Id":394125,"FormularyType":"OHP","DrugName":"CHEW CALCIUM CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903400535","GenericName":"CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG","NDC":"11917010164"},{"Id":394126,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917010165"},{"Id":394127,"FormularyType":"OHP","DrugName":"LIQUID B12 LIQ","DosageForm":"LIQD - Liquid","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000945","GenericName":"CYANOCOBALAMIN LIQUID 1000 MCG/15ML","NDC":"11917010170"},{"Id":394128,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917010200"},{"Id":394129,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917010202"},{"Id":394130,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917010203"},{"Id":394131,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"11917010208"},{"Id":394132,"FormularyType":"OHP","DrugName":"HEADACHE REL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"11917010235"},{"Id":394133,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917010268"},{"Id":394134,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917010270"},{"Id":394135,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917010271"},{"Id":394136,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917010272"},{"Id":394137,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917010273"},{"Id":394138,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917010274"},{"Id":394139,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917010275"},{"Id":394140,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917010279"},{"Id":394141,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917010300"},{"Id":394142,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917010301"},{"Id":394143,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917010302"},{"Id":394144,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917010303"},{"Id":394145,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917010304"},{"Id":394146,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917010305"},{"Id":394147,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"11917010306"},{"Id":394148,"FormularyType":"OHP","DrugName":"WAL-PHED D TAB 120MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"11917010310"},{"Id":394149,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"11917010335"},{"Id":394150,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"11917010336"},{"Id":394151,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"11917010337"},{"Id":394152,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"11917010341"},{"Id":394153,"FormularyType":"OHP","DrugName":"HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"11917010451"},{"Id":394154,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917010655"},{"Id":394155,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917010656"},{"Id":394156,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917010657"},{"Id":394157,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"11917010658"},{"Id":394158,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917010706"},{"Id":394159,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917010729"},{"Id":394160,"FormularyType":"OHP","DrugName":"HEADACHE REL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"11917010734"},{"Id":394161,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917010902"},{"Id":394162,"FormularyType":"OHP","DrugName":"EASY-LAX PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917010911"},{"Id":394163,"FormularyType":"OHP","DrugName":"EASY-LAX PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917010912"},{"Id":394164,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917010913"},{"Id":394165,"FormularyType":"OHP","DrugName":"SENNA S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917010914"},{"Id":394166,"FormularyType":"OHP","DrugName":"GLUCOSE GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"11917010927"},{"Id":394167,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917010948"},{"Id":394168,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL UNFLAVRD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917010949"},{"Id":394169,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FREEZER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917010950"},{"Id":394170,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11917011016"},{"Id":394171,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11917011017"},{"Id":394172,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917011024"},{"Id":394173,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917011025"},{"Id":394174,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917011028"},{"Id":394175,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917011069"},{"Id":394176,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917011070"},{"Id":394177,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917011072"},{"Id":394178,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917011073"},{"Id":394179,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917011077"},{"Id":394180,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917011096"},{"Id":394181,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917011097"},{"Id":394182,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"11917011201"},{"Id":394183,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"11917011202"},{"Id":394184,"FormularyType":"OHP","DrugName":"PAIN/FEVER SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"11917011271"},{"Id":394185,"FormularyType":"OHP","DrugName":"ALCOHOL WIPE MIS 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"11917011284"},{"Id":394186,"FormularyType":"OHP","DrugName":"CALCIUM 500 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11917011328"},{"Id":394187,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917011331"},{"Id":394188,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630368","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917011333"},{"Id":394189,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917011334"},{"Id":394190,"FormularyType":"OHP","DrugName":"CA CITRATE TAB + D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"11917011335"},{"Id":394191,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"11917011354"},{"Id":394192,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917011370"},{"Id":394193,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917011372"},{"Id":394194,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"11917011400"},{"Id":394195,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"11917011439"},{"Id":394196,"FormularyType":"OHP","DrugName":"ANTACID LIQ SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917011496"},{"Id":394197,"FormularyType":"OHP","DrugName":"ANTACID LIQ SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917011497"},{"Id":394198,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917011498"},{"Id":394199,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917011505"},{"Id":394200,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"11917011514"},{"Id":394201,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"11917011516"},{"Id":394202,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11917011540"},{"Id":394203,"FormularyType":"OHP","DrugName":"SLOW RELEASE TAB 47.5MG","DosageForm":"TBCR - Tablet ER","Strength":"47.5","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000457","GenericName":"FERROUS SULFATE TAB ER 47.5 MG (ELEMENTAL FE)","NDC":"11917011546"},{"Id":394204,"FormularyType":"OHP","DrugName":"GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"11917011568"},{"Id":394205,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917011593"},{"Id":394206,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"11917011651"},{"Id":394207,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"11917011652"},{"Id":394208,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL STRAWBRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917011655"},{"Id":394209,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917011658"},{"Id":394210,"FormularyType":"OHP","DrugName":"ALLRGY RELF TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"11917011742"},{"Id":394211,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917011810"},{"Id":394212,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917011811"},{"Id":394213,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917011818"},{"Id":394214,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917011819"},{"Id":394215,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917011820"},{"Id":394216,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917011822"},{"Id":394217,"FormularyType":"OHP","DrugName":"D3 CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"11917011823"},{"Id":394218,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917011917"},{"Id":394219,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917011918"},{"Id":394220,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917011919"},{"Id":394221,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917011925"},{"Id":394222,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917012054"},{"Id":394223,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"11917012057"},{"Id":394224,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"11917012058"},{"Id":394225,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"11917012068"},{"Id":394226,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012079"},{"Id":394227,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012080"},{"Id":394228,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012081"},{"Id":394229,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012082"},{"Id":394230,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012084"},{"Id":394231,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012085"},{"Id":394232,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917012086"},{"Id":394233,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917012181"},{"Id":394234,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917012182"},{"Id":394235,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917012183"},{"Id":394236,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917012184"},{"Id":394237,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917012195"},{"Id":394238,"FormularyType":"OHP","DrugName":"COVID-19 AT- KIT 2-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"11917012204"},{"Id":394239,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012271"},{"Id":394240,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917012314"},{"Id":394241,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917012353"},{"Id":394242,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917012354"},{"Id":394243,"FormularyType":"OHP","DrugName":"CHILD SOOTHE CHW 400MG","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000504","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG","NDC":"11917012408"},{"Id":394244,"FormularyType":"OHP","DrugName":"SOOTHE ULTRA TAB 525MG","DosageForm":"TABS - Tablet","Strength":"525","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000320","GenericName":"BISMUTH SUBSALICYLATE TAB 525 MG","NDC":"11917012479"},{"Id":394245,"FormularyType":"OHP","DrugName":"PAIN/FEVER SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"11917012480"},{"Id":394246,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917012498"},{"Id":394247,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917012697"},{"Id":394248,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917012698"},{"Id":394249,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917012703"},{"Id":394250,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012760"},{"Id":394251,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012761"},{"Id":394252,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917012805"},{"Id":394253,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012945"},{"Id":394254,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012946"},{"Id":394255,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012947"},{"Id":394256,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917012956"},{"Id":394257,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917012991"},{"Id":394258,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917012992"},{"Id":394259,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013004"},{"Id":394260,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013005"},{"Id":394261,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013006"},{"Id":394262,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013220"},{"Id":394263,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013221"},{"Id":394264,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013224"},{"Id":394265,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013229"},{"Id":394266,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013230"},{"Id":394267,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917013234"},{"Id":394268,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013294"},{"Id":394269,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"11917013296"},{"Id":394270,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"11917013297"},{"Id":394271,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"11917013298"},{"Id":394272,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013308"},{"Id":394273,"FormularyType":"OHP","DrugName":"GLUCOSE CHW FRUIT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013310"},{"Id":394274,"FormularyType":"OHP","DrugName":"GLUCOSE CHW TROP FRT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013311"},{"Id":394275,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013312"},{"Id":394276,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013313"},{"Id":394277,"FormularyType":"OHP","DrugName":"GLUCOSE CHW TROP FRT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917013315"},{"Id":394278,"FormularyType":"OHP","DrugName":"WAL-ITIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"11917013319"},{"Id":394279,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG ER","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"11917013327"},{"Id":394280,"FormularyType":"OHP","DrugName":"B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917013368"},{"Id":394281,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917013522"},{"Id":394282,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917013588"},{"Id":394283,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"11917013632"},{"Id":394284,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"11917013634"},{"Id":394285,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917013643"},{"Id":394286,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917013650"},{"Id":394287,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917013651"},{"Id":394288,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917013694"},{"Id":394289,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"11917013704"},{"Id":394290,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917013753"},{"Id":394291,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917013754"},{"Id":394292,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917013755"},{"Id":394293,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917013756"},{"Id":394294,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917013757"},{"Id":394295,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917013758"},{"Id":394296,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917013828"},{"Id":394297,"FormularyType":"OHP","DrugName":"LIQUID B12 LIQ 1000/15","DosageForm":"LIQD - Liquid","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000945","GenericName":"CYANOCOBALAMIN LIQUID 1000 MCG/15ML","NDC":"11917013852"},{"Id":394298,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917013858"},{"Id":394299,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917013861"},{"Id":394300,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917013868"},{"Id":394301,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917013869"},{"Id":394302,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917013870"},{"Id":394303,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917013874"},{"Id":394304,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917013875"},{"Id":394305,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917013892"},{"Id":394306,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917013893"},{"Id":394307,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917013894"},{"Id":394308,"FormularyType":"OHP","DrugName":"NIACIN CAP 250MG TR","DosageForm":"CPCR - Capsule ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000210","GenericName":"NIACIN CAP ER 250 MG","NDC":"11917013919"},{"Id":394309,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"11917013922"},{"Id":394310,"FormularyType":"OHP","DrugName":"B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917013932"},{"Id":394311,"FormularyType":"OHP","DrugName":"B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917013933"},{"Id":394312,"FormularyType":"OHP","DrugName":"B-COMPLEX TAB VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917013935"},{"Id":394313,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917013940"},{"Id":394314,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917013941"},{"Id":394315,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917013942"},{"Id":394316,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917013943"},{"Id":394317,"FormularyType":"OHP","DrugName":"D3 CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"11917013944"},{"Id":394318,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917013952"},{"Id":394319,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"11917013953"},{"Id":394320,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"11917013956"},{"Id":394321,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"11917013961"},{"Id":394322,"FormularyType":"OHP","DrugName":"B-12 TR TAB 1000 MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917013963"},{"Id":394323,"FormularyType":"OHP","DrugName":"B-12 TR TAB 1000 MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917013964"},{"Id":394324,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"11917013967"},{"Id":394325,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917013971"},{"Id":394326,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917013972"},{"Id":394327,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917013973"},{"Id":394328,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11917013981"},{"Id":394329,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917013988"},{"Id":394330,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"11917013989"},{"Id":394331,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000145","GenericName":"VITAMIN E CAP 1000 UNIT","NDC":"11917013991"},{"Id":394332,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"11917014057"},{"Id":394333,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 5MG/15ML","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000930","GenericName":"MELATONIN LIQUID 5 MG/15ML","NDC":"11917014142"},{"Id":394334,"FormularyType":"OHP","DrugName":"PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917014144"},{"Id":394335,"FormularyType":"OHP","DrugName":"FISH OIL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"11917014179"},{"Id":394336,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"11917014190"},{"Id":394337,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"11917014191"},{"Id":394338,"FormularyType":"OHP","DrugName":"GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"11917014205"},{"Id":394339,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"11917014221"},{"Id":394340,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917014296"},{"Id":394341,"FormularyType":"OHP","DrugName":"ALCOHOL WIPE MIS 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"11917014301"},{"Id":394342,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11917014360"},{"Id":394343,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1GM","DosageForm":"SUPP - Suppository","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005206","GenericName":"GLYCERIN SUPPOS 1 GM","NDC":"11917014445"},{"Id":394344,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"11917014446"},{"Id":394345,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"11917014447"},{"Id":394346,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"11917014448"},{"Id":394347,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917014449"},{"Id":394348,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"11917014455"},{"Id":394349,"FormularyType":"OHP","DrugName":"MOLESKIN PAD FOAM","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"11917014473"},{"Id":394350,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"11917014587"},{"Id":394351,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917014592"},{"Id":394352,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"11917014611"},{"Id":394353,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"11917014666"},{"Id":394354,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917014667"},{"Id":394355,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917014668"},{"Id":394356,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"11917014669"},{"Id":394357,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917014671"},{"Id":394358,"FormularyType":"OHP","DrugName":"B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"11917014672"},{"Id":394359,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917014678"},{"Id":394360,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917014679"},{"Id":394361,"FormularyType":"OHP","DrugName":"CALCIUM+D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917014682"},{"Id":394362,"FormularyType":"OHP","DrugName":"CALCIUM+D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917014683"},{"Id":394363,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11917014685"},{"Id":394364,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917014763"},{"Id":394365,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917014764"},{"Id":394366,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917014765"},{"Id":394367,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11917014767"},{"Id":394368,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE -TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917014775"},{"Id":394369,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE -TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917014776"},{"Id":394370,"FormularyType":"OHP","DrugName":"MINERAL OIL ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010005110","GenericName":"MINERAL OIL ENEMA","NDC":"11917014777"},{"Id":394371,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE -TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917014778"},{"Id":394372,"FormularyType":"OHP","DrugName":"ATHLETE FOOT POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"11917014800"},{"Id":394373,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"11917014802"},{"Id":394374,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"11917014835"},{"Id":394375,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917014837"},{"Id":394376,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"11917014860"},{"Id":394377,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"11917014868"},{"Id":394378,"FormularyType":"OHP","DrugName":"WAL-ITIN CHL SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"11917014991"},{"Id":394379,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917015039"},{"Id":394380,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4-.006GM","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917015040"},{"Id":394381,"FormularyType":"OHP","DrugName":"NUTR DRINK POW MIX VAN","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"11917015107"},{"Id":394382,"FormularyType":"OHP","DrugName":"NUTR DRINK POW MIX CHOC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"11917015108"},{"Id":394383,"FormularyType":"OHP","DrugName":"COMFORT GEL SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917015116"},{"Id":394384,"FormularyType":"OHP","DrugName":"IBUPROFN 100 CHW JR 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"11917015169"},{"Id":394385,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917015176"},{"Id":394386,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917015179"},{"Id":394387,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917015181"},{"Id":394388,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917015182"},{"Id":394389,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917015185"},{"Id":394390,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917015293"},{"Id":394391,"FormularyType":"OHP","DrugName":"ORAL ELECTRO SOL FREEZER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917015306"},{"Id":394392,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"11917015327"},{"Id":394393,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"11917015350"},{"Id":394394,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917015378"},{"Id":394395,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917015380"},{"Id":394396,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917015381"},{"Id":394397,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917015382"},{"Id":394398,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917015383"},{"Id":394399,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917015384"},{"Id":394400,"FormularyType":"OHP","DrugName":"NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917015387"},{"Id":394401,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917015395"},{"Id":394402,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917015396"},{"Id":394403,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917015397"},{"Id":394404,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917015398"},{"Id":394405,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917015399"},{"Id":394406,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917015400"},{"Id":394407,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917015401"},{"Id":394408,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917015404"},{"Id":394409,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917015425"},{"Id":394410,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917015435"},{"Id":394411,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917015437"},{"Id":394412,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917015441"},{"Id":394413,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917015461"},{"Id":394414,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917015462"},{"Id":394415,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917015468"},{"Id":394416,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917015469"},{"Id":394417,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917015470"},{"Id":394418,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"99.9","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"11917015471"},{"Id":394419,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"11917015562"},{"Id":394420,"FormularyType":"OHP","DrugName":"ANTACID & SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917015590"},{"Id":394421,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917015592"},{"Id":394422,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917015593"},{"Id":394423,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917015595"},{"Id":394424,"FormularyType":"OHP","DrugName":"ELECTROLYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917015633"},{"Id":394425,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917015657"},{"Id":394426,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917015658"},{"Id":394427,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"11917015664"},{"Id":394428,"FormularyType":"OHP","DrugName":"PRENATL MULT CAP + DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000130","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 27-0.8-250 MG***","NDC":"11917015670"},{"Id":394429,"FormularyType":"OHP","DrugName":"NUTRITIONAL POW SHAK MIX","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"11917015687"},{"Id":394430,"FormularyType":"OHP","DrugName":"NUTRITIONAL POW SHAK MIX","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"11917015688"},{"Id":394431,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917015690"},{"Id":394432,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917015691"},{"Id":394433,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"11917015692"},{"Id":394434,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917015693"},{"Id":394435,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917015953"},{"Id":394436,"FormularyType":"OHP","DrugName":"WAL-SLEEP Z CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"11917015969"},{"Id":394437,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917015973"},{"Id":394438,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"11917016002"},{"Id":394439,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917016003"},{"Id":394440,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"11917016081"},{"Id":394441,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"11917016082"},{"Id":394442,"FormularyType":"OHP","DrugName":"PEDIATRIC ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105110","GenericName":"*SODIUM PHOSPHATES - ENEMA (PEDIATRIC)***","NDC":"11917016145"},{"Id":394443,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917016172"},{"Id":394444,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"11917016173"},{"Id":394445,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917016177"},{"Id":394446,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917016178"},{"Id":394447,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917016194"},{"Id":394448,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917016195"},{"Id":394449,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917016196"},{"Id":394450,"FormularyType":"OHP","DrugName":"WAL-MUCIL POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"11917016225"},{"Id":394451,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917016232"},{"Id":394452,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917016233"},{"Id":394453,"FormularyType":"OHP","DrugName":"GLYCERN CHLD SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"11917016258"},{"Id":394454,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917016262"},{"Id":394455,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917016263"},{"Id":394456,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"11917016264"},{"Id":394457,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917016295"},{"Id":394458,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ PLS PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917016298"},{"Id":394459,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ PLS PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917016299"},{"Id":394460,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN MAX ST","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"11917016332"},{"Id":394461,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917016334"},{"Id":394462,"FormularyType":"OHP","DrugName":"WAL-DRYL ALR TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"11917016360"},{"Id":394463,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917016366"},{"Id":394464,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917016367"},{"Id":394465,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917016368"},{"Id":394466,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917016369"},{"Id":394467,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917016373"},{"Id":394468,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"11917016375"},{"Id":394469,"FormularyType":"OHP","DrugName":"ASPIRIN 81 TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917016378"},{"Id":394470,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917016379"},{"Id":394471,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"11917016381"},{"Id":394472,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"11917016390"},{"Id":394473,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"11917016394"},{"Id":394474,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917016407"},{"Id":394475,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"11917016408"},{"Id":394476,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917016409"},{"Id":394477,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN MAX ST","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"11917016411"},{"Id":394478,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917016441"},{"Id":394479,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917016446"},{"Id":394480,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917016537"},{"Id":394481,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917016539"},{"Id":394482,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917016540"},{"Id":394483,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917016582"},{"Id":394484,"FormularyType":"OHP","DrugName":"CALC CITR+D3 TAB 200-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"11917016630"},{"Id":394485,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917016632"},{"Id":394486,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11917016636"},{"Id":394487,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"11917016663"},{"Id":394488,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"11917016681"},{"Id":394489,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917016683"},{"Id":394490,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917016684"},{"Id":394491,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917016736"},{"Id":394492,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917016737"},{"Id":394493,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917016740"},{"Id":394494,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"11917016741"},{"Id":394495,"FormularyType":"OHP","DrugName":"GLUCOSE CHW TROP FRT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917016742"},{"Id":394496,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917016743"},{"Id":394497,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBRRY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917016744"},{"Id":394498,"FormularyType":"OHP","DrugName":"GLUCOSE CHW TROP FRT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917016745"},{"Id":394499,"FormularyType":"OHP","DrugName":"GLUCOSE CHW FRUIT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"11917016746"},{"Id":394500,"FormularyType":"OHP","DrugName":"WAL-SOM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"11917016764"},{"Id":394501,"FormularyType":"OHP","DrugName":"ATHLETE FOOT POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"11917016787"},{"Id":394502,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"11917016878"},{"Id":394503,"FormularyType":"OHP","DrugName":"ANTACID SUS ADVANCED","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917016879"},{"Id":394504,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"11917016889"},{"Id":394505,"FormularyType":"OHP","DrugName":"GLUCOSE GEL 15GM/33G","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004045","GenericName":"GLUCOSE GEL 15 GM/33GM","NDC":"11917016944"},{"Id":394506,"FormularyType":"OHP","DrugName":"ORAL ELECTRO SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"11917016962"},{"Id":394507,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017013"},{"Id":394508,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017014"},{"Id":394509,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ PLS PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017015"},{"Id":394510,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ PLS PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017016"},{"Id":394511,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917017020"},{"Id":394512,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"11917017023"},{"Id":394513,"FormularyType":"OHP","DrugName":"HGH-POT IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917017060"},{"Id":394514,"FormularyType":"OHP","DrugName":"IRON HP TAB 27MG","DosageForm":"TABS - Tablet","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"11917017063"},{"Id":394515,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917017065"},{"Id":394516,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"11917017067"},{"Id":394517,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917017079"},{"Id":394518,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917017080"},{"Id":394519,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"11917017081"},{"Id":394520,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"11917017085"},{"Id":394521,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917017094"},{"Id":394522,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917017096"},{"Id":394523,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917017102"},{"Id":394524,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"11917017106"},{"Id":394525,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11917017122"},{"Id":394526,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"11917017124"},{"Id":394527,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"11917017126"},{"Id":394528,"FormularyType":"OHP","DrugName":"PRENATAL TAB MULTIVIT","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"11917017127"},{"Id":394529,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917017168"},{"Id":394530,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"11917017169"},{"Id":394531,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"11917017170"},{"Id":394532,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"11917017175"},{"Id":394533,"FormularyType":"OHP","DrugName":"CALC CIT+D3 TAB 200-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"11917017177"},{"Id":394534,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"11917017180"},{"Id":394535,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917017181"},{"Id":394536,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917017182"},{"Id":394537,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"11917017183"},{"Id":394538,"FormularyType":"OHP","DrugName":"PRENTAT MULT CAP PLUS DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000130","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 27-0.8-250 MG***","NDC":"11917017184"},{"Id":394539,"FormularyType":"OHP","DrugName":"IRON TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"11917017213"},{"Id":394540,"FormularyType":"OHP","DrugName":"NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"11917017228"},{"Id":394541,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917017229"},{"Id":394542,"FormularyType":"OHP","DrugName":"NICOTINE DIS STEP 1","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917017230"},{"Id":394543,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917017231"},{"Id":394544,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"11917017248"},{"Id":394545,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"11917017252"},{"Id":394546,"FormularyType":"OHP","DrugName":"WAL-FEX ALLR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917017265"},{"Id":394547,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11917017321"},{"Id":394548,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017378"},{"Id":394549,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017379"},{"Id":394550,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017380"},{"Id":394551,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017381"},{"Id":394552,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017382"},{"Id":394553,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917017512"},{"Id":394554,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917017513"},{"Id":394555,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"11917017514"},{"Id":394556,"FormularyType":"OHP","DrugName":"ANTACID FLAV CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917017608"},{"Id":394557,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"11917017652"},{"Id":394558,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"11917017659"},{"Id":394559,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ PLS PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017720"},{"Id":394560,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ PLS PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917017722"},{"Id":394561,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917017736"},{"Id":394562,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917017756"},{"Id":394563,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"11917017758"},{"Id":394564,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917017759"},{"Id":394565,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917017764"},{"Id":394566,"FormularyType":"OHP","DrugName":"WAL-ITIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"11917017782"},{"Id":394567,"FormularyType":"OHP","DrugName":"WAL-PHED TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"11917017783"},{"Id":394568,"FormularyType":"OHP","DrugName":"WAL-DRYL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"11917017793"},{"Id":394569,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917017912"},{"Id":394570,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917017924"},{"Id":394571,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917017925"},{"Id":394572,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917017934"},{"Id":394573,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917017935"},{"Id":394574,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917017958"},{"Id":394575,"FormularyType":"OHP","DrugName":"WAL-ZYR CHLD SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917017959"},{"Id":394576,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917017966"},{"Id":394577,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917017970"},{"Id":394578,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917018001"},{"Id":394579,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"11917018065"},{"Id":394580,"FormularyType":"OHP","DrugName":"SMOOTH LAX POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"11917018069"},{"Id":394581,"FormularyType":"OHP","DrugName":"WAL-ZYR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"11917018209"},{"Id":394582,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917018245"},{"Id":394583,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917018247"},{"Id":394584,"FormularyType":"OHP","DrugName":"ALLERGY NASA SPR 24HR","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"11917018284"},{"Id":394585,"FormularyType":"OHP","DrugName":"PINWORM MED SUS 144MG/ML","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"11917018294"},{"Id":394586,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"11917018296"},{"Id":394587,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"11917018320"},{"Id":394588,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 1MG/ML","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000940","GenericName":"MELATONIN LIQUID 1 MG/ML","NDC":"11917018468"},{"Id":394589,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"11917018506"},{"Id":394590,"FormularyType":"OHP","DrugName":"PEDIATRIC ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105110","GenericName":"*SODIUM PHOSPHATES - ENEMA (PEDIATRIC)***","NDC":"11917018510"},{"Id":394591,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"11917018541"},{"Id":394592,"FormularyType":"OHP","DrugName":"D3 CAP 10000","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"11917018556"},{"Id":394593,"FormularyType":"OHP","DrugName":"WAL-FEX ALRG TAB 60MG 12H","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"11917018625"},{"Id":394594,"FormularyType":"OHP","DrugName":"WAL-FEX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"11917018715"},{"Id":394595,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"11917018788"},{"Id":394596,"FormularyType":"OHP","DrugName":"ALLERGY NASA SPR 24HR","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"11917018809"},{"Id":394597,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"11917018851"},{"Id":394598,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"11917018855"},{"Id":394599,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"11917018856"},{"Id":394600,"FormularyType":"OHP","DrugName":"B COMPLEX TAB VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"11917018871"},{"Id":394601,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"11917018955"},{"Id":394602,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"11917018956"},{"Id":394603,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"11917019004"},{"Id":394604,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"11917019006"},{"Id":394605,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"11917019061"},{"Id":394606,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"11917019062"},{"Id":394607,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"11917019075"},{"Id":394608,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"11917019076"},{"Id":394609,"FormularyType":"OHP","DrugName":"PRENATAL+DHA MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006318","GenericName":"*PRENATAL W/FE FUM-FA TAB 28-0.975 MG & DHA CAP 200 MG PACK*","NDC":"11917019108"},{"Id":394610,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"11917019289"},{"Id":394611,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"11917019317"},{"Id":394612,"FormularyType":"OHP","DrugName":"WAL-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"11917019433"},{"Id":394613,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"11917019544"},{"Id":394614,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"11917019692"},{"Id":394615,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"11917019726"},{"Id":394616,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"11917019792"},{"Id":394617,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917019833"},{"Id":394618,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917019835"},{"Id":394619,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917019841"},{"Id":394620,"FormularyType":"OHP","DrugName":"STOOL SOFTEN LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"11917019866"},{"Id":394621,"FormularyType":"OHP","DrugName":"MELATONIN SUB 5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000740","GenericName":"MELATONIN SL TAB 5 MG","NDC":"11917019901"},{"Id":394622,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917020012"},{"Id":394623,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"11917020013"},{"Id":394624,"FormularyType":"OHP","DrugName":"ATHLETE FOOT POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"11917020102"},{"Id":394625,"FormularyType":"OHP","DrugName":"REGULAR LIQ NUTRITIO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"11917020132"},{"Id":394626,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917020159"},{"Id":394627,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"11917020160"},{"Id":394628,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"11917020187"},{"Id":394629,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917020190"},{"Id":394630,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"11917020205"},{"Id":394631,"FormularyType":"OHP","DrugName":"WAL-ZYR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"11917020220"},{"Id":394632,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"11917020311"},{"Id":394633,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"11917020312"},{"Id":394634,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"11917020327"},{"Id":394635,"FormularyType":"OHP","DrugName":"WAL-PHED D TAB 120MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"11917020333"},{"Id":394636,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917020345"},{"Id":394637,"FormularyType":"OHP","DrugName":"IRON HP TAB 65MG","DosageForm":"TABS - Tablet","Strength":"65","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100324","GenericName":"FERROUS SULFATE DRIED TAB 209 MG (65 MG ELEMENTAL FE)","NDC":"11917020439"},{"Id":394638,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"11917020508"},{"Id":394639,"FormularyType":"OHP","DrugName":"SOOTHE TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"11917020521"},{"Id":394640,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917020651"},{"Id":394641,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917020833"},{"Id":394642,"FormularyType":"OHP","DrugName":"NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"11917020875"},{"Id":394643,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"11917020881"},{"Id":394644,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917020883"},{"Id":394645,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"11917020886"},{"Id":394646,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917021080"},{"Id":394647,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917021088"},{"Id":394648,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"11917021090"},{"Id":394649,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"11917021287"},{"Id":394650,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"11917021360"},{"Id":394651,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"11917021364"},{"Id":394652,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"11917021403"},{"Id":394653,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"11917021517"},{"Id":394654,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"11917021589"},{"Id":394655,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"11917021641"},{"Id":394656,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"11917021714"},{"Id":394657,"FormularyType":"OHP","DrugName":"PRENATAL CHW GUMMIES","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000524","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.18-25 MG***","NDC":"11917021724"},{"Id":394658,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917021804"},{"Id":394659,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"11917021805"},{"Id":394660,"FormularyType":"OHP","DrugName":"WAL-FEX ALRG TAB 60MG 12H","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"11917021854"},{"Id":394661,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"11917021979"},{"Id":394662,"FormularyType":"OHP","DrugName":"PRENATAL TAB FOLATE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000315","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG***","NDC":"11917022012"},{"Id":394663,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"11917022013"},{"Id":394664,"FormularyType":"OHP","DrugName":"FINEST NUTRT CAP VIT D3","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"11917022014"},{"Id":394665,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"11917022039"},{"Id":394666,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH REL","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"11917022048"},{"Id":394667,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH/RED","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"11917022049"},{"Id":394668,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"11917022062"},{"Id":394669,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"11917022069"},{"Id":394670,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"11917022075"},{"Id":394671,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH REL","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"11917022115"},{"Id":394672,"FormularyType":"OHP","DrugName":"PRED MILD SUS 0.12% OP","DosageForm":"SUSP - Suspension","Strength":"0.12","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101809","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 0.12%","NDC":"11980017405"},{"Id":394673,"FormularyType":"OHP","DrugName":"PRED MILD SUS 0.12% OP","DosageForm":"SUSP - Suspension","Strength":"0.12","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101809","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 0.12%","NDC":"11980017410"},{"Id":394674,"FormularyType":"OHP","DrugName":"FML FORTE SUS 0.25% OP","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300020001820","GenericName":"FLUOROMETHOLONE OPHTH SUSP 0.25%","NDC":"11980022805"},{"Id":394675,"FormularyType":"OHP","DrugName":"FML FORTE SUS 0.25% OP","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300020001820","GenericName":"FLUOROMETHOLONE OPHTH SUSP 0.25%","NDC":"11980022810"},{"Id":394676,"FormularyType":"OHP","DrugName":"DANDRUF SHAM SHA /COND 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"12277005126"},{"Id":394677,"FormularyType":"OHP","DrugName":"PSORIAS SHAM SHA /COND 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"12277005127"},{"Id":394678,"FormularyType":"OHP","DrugName":"INSUPEN32G MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"12383003044"},{"Id":394679,"FormularyType":"OHP","DrugName":"INSUPEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"12383003082"},{"Id":394680,"FormularyType":"OHP","DrugName":"INSUPEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"12383003083"},{"Id":394681,"FormularyType":"OHP","DrugName":"INSUPEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"12383003084"},{"Id":394682,"FormularyType":"OHP","DrugName":"OPVEE SPR 2.7/0.1","DosageForm":"SOLN - Solution","Strength":"2.7","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400018102060","GenericName":"NALMEFENE HCL NASAL SPRAY 2.7 MG/0.1ML (BASE EQUIV)","NDC":"12496000301"},{"Id":394683,"FormularyType":"OHP","DrugName":"OPVEE SPR 2.7/0.1","DosageForm":"SOLN - Solution","Strength":"2.7","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400018102060","GenericName":"NALMEFENE HCL NASAL SPRAY 2.7 MG/0.1ML (BASE EQUIV)","NDC":"12496000302"},{"Id":394684,"FormularyType":"OHP","DrugName":"SUBLOCADE INJ 100/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E520","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 100 MG/0.5ML","NDC":"12496010001"},{"Id":394685,"FormularyType":"OHP","DrugName":"SUBLOCADE INJ 100/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E520","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 100 MG/0.5ML","NDC":"12496010005"},{"Id":394686,"FormularyType":"OHP","DrugName":"SUBLOCADE INJ 300/1.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E530","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 300 MG/1.5ML","NDC":"12496030001"},{"Id":394687,"FormularyType":"OHP","DrugName":"SUBLOCADE INJ 300/1.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E530","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 300 MG/1.5ML","NDC":"12496030005"},{"Id":394688,"FormularyType":"OHP","DrugName":"PKU COOLR 10 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002036"},{"Id":394689,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002037"},{"Id":394690,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002038"},{"Id":394691,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002040"},{"Id":394692,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002041"},{"Id":394693,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ PURPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002043"},{"Id":394694,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ PURPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002044"},{"Id":394695,"FormularyType":"OHP","DrugName":"MSUD COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002055"},{"Id":394696,"FormularyType":"OHP","DrugName":"MSUD COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002057"},{"Id":394697,"FormularyType":"OHP","DrugName":"HCU COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002064"},{"Id":394698,"FormularyType":"OHP","DrugName":"HCU COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002066"},{"Id":394699,"FormularyType":"OHP","DrugName":"TYR COOLER LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002073"},{"Id":394700,"FormularyType":"OHP","DrugName":"TYR COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002075"},{"Id":394701,"FormularyType":"OHP","DrugName":"MMA/PA LIQ COOLER15","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002077"},{"Id":394702,"FormularyType":"OHP","DrugName":"LIPISTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002133"},{"Id":394703,"FormularyType":"OHP","DrugName":"LIPISTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002147"},{"Id":394704,"FormularyType":"OHP","DrugName":"RENASTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002148"},{"Id":394705,"FormularyType":"OHP","DrugName":"RENASTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002149"},{"Id":394706,"FormularyType":"OHP","DrugName":"PKU AIR20 LIQ GOLD","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002169"},{"Id":394707,"FormularyType":"OHP","DrugName":"PKU AIR20 LIQ GREEN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002170"},{"Id":394708,"FormularyType":"OHP","DrugName":"PKU AIR20 LIQ YELLOW","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002171"},{"Id":394709,"FormularyType":"OHP","DrugName":"RENASTEP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002484"},{"Id":394710,"FormularyType":"OHP","DrugName":"KFLO LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002577"},{"Id":394711,"FormularyType":"OHP","DrugName":"PKU SPHERE LIQ 20 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002584"},{"Id":394712,"FormularyType":"OHP","DrugName":"PKU START POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002590"},{"Id":394713,"FormularyType":"OHP","DrugName":"RENASTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002597"},{"Id":394714,"FormularyType":"OHP","DrugName":"RENASTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"12539002598"},{"Id":394715,"FormularyType":"OHP","DrugName":"PKU SPHERE LIQ NEXT 15","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002600"},{"Id":394716,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002603"},{"Id":394717,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002604"},{"Id":394718,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ PURPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002605"},{"Id":394719,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ PURPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002606"},{"Id":394720,"FormularyType":"OHP","DrugName":"PKU COOLR 10 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002607"},{"Id":394721,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002608"},{"Id":394722,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002609"},{"Id":394723,"FormularyType":"OHP","DrugName":"MSUD COOLER LIQ 15 ORANG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002616"},{"Id":394724,"FormularyType":"OHP","DrugName":"MSUD COOLER LIQ 15 RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"12539002617"},{"Id":394725,"FormularyType":"OHP","DrugName":"NEOSPORIN OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"12547023808"},{"Id":394726,"FormularyType":"OHP","DrugName":"NEOSPORIN OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"12547023809"},{"Id":394727,"FormularyType":"OHP","DrugName":"NEOSPORIN+PN OIN RELF MAX","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"12547023815"},{"Id":394728,"FormularyType":"OHP","DrugName":"NEOSPORIN OIN BURN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"12547023836"},{"Id":394729,"FormularyType":"OHP","DrugName":"BAYER LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"12843010105"},{"Id":394730,"FormularyType":"OHP","DrugName":"BAYER LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"12843013105"},{"Id":394731,"FormularyType":"OHP","DrugName":"BAYER LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"12843013231"},{"Id":394732,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"12843035303"},{"Id":394733,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"12843036305"},{"Id":394734,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"12843036306"},{"Id":394735,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"12843039324"},{"Id":394736,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"12843039325"},{"Id":394737,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"12843052580"},{"Id":394738,"FormularyType":"OHP","DrugName":"BAYER ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"12843053635"},{"Id":394739,"FormularyType":"OHP","DrugName":"BAYER ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"12843053636"},{"Id":394740,"FormularyType":"OHP","DrugName":"BAYER LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"12843053637"},{"Id":394741,"FormularyType":"OHP","DrugName":"BAYER LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"12843053642"},{"Id":394742,"FormularyType":"OHP","DrugName":"BAYER ADV TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"12843054579"},{"Id":394743,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"12843055104"},{"Id":394744,"FormularyType":"OHP","DrugName":"BAYER ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"12843055536"},{"Id":394745,"FormularyType":"OHP","DrugName":"GENUINE ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"12843055537"},{"Id":394746,"FormularyType":"OHP","DrugName":"ALFAMINO POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"13034078795"},{"Id":394747,"FormularyType":"OHP","DrugName":"HYDROCOD/IBU TAB 7.5-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702500320","GenericName":"HYDROCODONE-IBUPROFEN TAB 7.5-200 MG","NDC":"13107000401"},{"Id":394748,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"13107001901"},{"Id":394749,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"13107001905"},{"Id":394750,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"13107002001"},{"Id":394751,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"13107002005"},{"Id":394752,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"13107002101"},{"Id":394753,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"13107002105"},{"Id":394754,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"13107002199"},{"Id":394755,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"13107003501"},{"Id":394756,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"13107003601"},{"Id":394757,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"13107004401"},{"Id":394758,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"13107004405"},{"Id":394759,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"13107004501"},{"Id":394760,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"13107004505"},{"Id":394761,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"13107004601"},{"Id":394762,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"13107004605"},{"Id":394763,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"13107005501"},{"Id":394764,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"13107005601"},{"Id":394765,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"13107005701"},{"Id":394766,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050310","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","NDC":"13107005801"},{"Id":394767,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"13107005901"},{"Id":394768,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"13107005999"},{"Id":394769,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"13107006001"},{"Id":394770,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"13107006005"},{"Id":394771,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"13107006099"},{"Id":394772,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"13107006801"},{"Id":394773,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"13107007001"},{"Id":394774,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"13107007201"},{"Id":394775,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"13107007301"},{"Id":394776,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"13107007401"},{"Id":394777,"FormularyType":"OHP","DrugName":"ALFAMINO POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"13287010606"},{"Id":394778,"FormularyType":"OHP","DrugName":"THERA-D TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"13349001022"},{"Id":394779,"FormularyType":"OHP","DrugName":"THERA-D TAB 4000UNIT","DosageForm":"TABS - Tablet","Strength":"4000","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000346","GenericName":"CHOLECALCIFEROL TAB 100 MCG (4000 UNIT)","NDC":"13349001023"},{"Id":394780,"FormularyType":"OHP","DrugName":"THEROMEGA CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"13349001026"},{"Id":394781,"FormularyType":"OHP","DrugName":"THEROMEGA CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"13349001028"},{"Id":394782,"FormularyType":"OHP","DrugName":"THERA-D TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"13349001045"},{"Id":394783,"FormularyType":"OHP","DrugName":"DIAZOXIDE SUS 50MG/ML","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300020001810","GenericName":"DIAZOXIDE SUSP 50 MG/ML","NDC":"13517010030"},{"Id":394784,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"13517020716"},{"Id":394785,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"13517062501"},{"Id":394786,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"13517062510"},{"Id":394787,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"13517062601"},{"Id":394788,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"13517062610"},{"Id":394789,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"13517062701"},{"Id":394790,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"13517062710"},{"Id":394791,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"13517062801"},{"Id":394792,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"13517062810"},{"Id":394793,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"13517069201"},{"Id":394794,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"13517069301"},{"Id":394795,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"13517069305"},{"Id":394796,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"13517069401"},{"Id":394797,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"13517069405"},{"Id":394798,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"13668000701"},{"Id":394799,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"13668000705"},{"Id":394800,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"13668000710"},{"Id":394801,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"13668000715"},{"Id":394802,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"13668000801"},{"Id":394803,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"13668000805"},{"Id":394804,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"13668000810"},{"Id":394805,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"13668000815"},{"Id":394806,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"13668001612"},{"Id":394807,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"13668007905"},{"Id":394808,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"13668007930"},{"Id":394809,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"13668007990"},{"Id":394810,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"13668008005"},{"Id":394811,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"13668008030"},{"Id":394812,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"13668008090"},{"Id":394813,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"13668008105"},{"Id":394814,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"13668008130"},{"Id":394815,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"13668008190"},{"Id":394816,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"13668009105"},{"Id":394817,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"13668009190"},{"Id":394818,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"13668009205"},{"Id":394819,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"13668009290"},{"Id":394820,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"13668009305"},{"Id":394821,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"13668009390"},{"Id":394822,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"13668009405"},{"Id":394823,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"13668009490"},{"Id":394824,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"13668009505"},{"Id":394825,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"13668009590"},{"Id":394826,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"13668009690"},{"Id":394827,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"13668010210"},{"Id":394828,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"13668010230"},{"Id":394829,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"13668010290"},{"Id":394830,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"13668010310"},{"Id":394831,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"13668010330"},{"Id":394832,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"13668010390"},{"Id":394833,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"13668010401"},{"Id":394834,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"13668010410"},{"Id":394835,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"13668010501"},{"Id":394836,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"13668010510"},{"Id":394837,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 120MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007540","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG","NDC":"13668010601"},{"Id":394838,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"13668010730"},{"Id":394839,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"13668010790"},{"Id":394840,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"13668013201"},{"Id":394841,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"13668013205"},{"Id":394842,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"13668013210"},{"Id":394843,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"13668013301"},{"Id":394844,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"13668013305"},{"Id":394845,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"13668013310"},{"Id":394846,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"13668013401"},{"Id":394847,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"13668013405"},{"Id":394848,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"13668013410"},{"Id":394849,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"13668014105"},{"Id":394850,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"13668014130"},{"Id":394851,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"13668014190"},{"Id":394852,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"13668017905"},{"Id":394853,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"13668017930"},{"Id":394854,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"13668017990"},{"Id":394855,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"13668018005"},{"Id":394856,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"13668018030"},{"Id":394857,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"13668018090"},{"Id":394858,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"13668018105"},{"Id":394859,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"13668018130"},{"Id":394860,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"13668018190"},{"Id":394861,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"13668018205"},{"Id":394862,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"13668018230"},{"Id":394863,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"13668018405"},{"Id":394864,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"13668018490"},{"Id":394865,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"13668018590"},{"Id":394866,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"13668018905"},{"Id":394867,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"13668018930"},{"Id":394868,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"13668018990"},{"Id":394869,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"13668019005"},{"Id":394870,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"13668019030"},{"Id":394871,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"13668019090"},{"Id":394872,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"13668026801"},{"Id":394873,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"13668026805"},{"Id":394874,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"13668026810"},{"Id":394875,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000505","GenericName":"CARBAMAZEPINE CHEW TAB 100 MG","NDC":"13668027101"},{"Id":394876,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000505","GenericName":"CARBAMAZEPINE CHEW TAB 100 MG","NDC":"13668027105"},{"Id":394877,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"13668028401"},{"Id":394878,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"13668028501"},{"Id":394879,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"13668028601"},{"Id":394880,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"13668035805"},{"Id":394881,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"13668035905"},{"Id":394882,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"13668036005"},{"Id":394883,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"13668036105"},{"Id":394884,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"13668036205"},{"Id":394885,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"13668036305"},{"Id":394886,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"13668036405"},{"Id":394887,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"13668036505"},{"Id":394888,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"13668042905"},{"Id":394889,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"13668042990"},{"Id":394890,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"13668043801"},{"Id":394891,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"13668043901"},{"Id":394892,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"13668044001"},{"Id":394893,"FormularyType":"OHP","DrugName":"ANAGRELIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85156010100120","GenericName":"ANAGRELIDE HCL CAP 0.5 MG","NDC":"13668045301"},{"Id":394894,"FormularyType":"OHP","DrugName":"ANAGRELIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85156010100130","GenericName":"ANAGRELIDE HCL CAP 1 MG","NDC":"13668046201"},{"Id":394895,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"13668046330"},{"Id":394896,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"13668048201"},{"Id":394897,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"13668048405"},{"Id":394898,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"13668048450"},{"Id":394899,"FormularyType":"OHP","DrugName":"MOMETASONE OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082104210","GenericName":"MOMETASONE FUROATE OINT 0.1%","NDC":"13668052701"},{"Id":394900,"FormularyType":"OHP","DrugName":"MOMETASONE OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082104210","GenericName":"MOMETASONE FUROATE OINT 0.1%","NDC":"13668052704"},{"Id":394901,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"13668053111"},{"Id":394902,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"13668053194"},{"Id":394903,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"13668053401"},{"Id":394904,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"13668053402"},{"Id":394905,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"13668056901"},{"Id":394906,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"13668056902"},{"Id":394907,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"13668056904"},{"Id":394908,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"13668056905"},{"Id":394909,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"13668058130"},{"Id":394910,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"13668059181"},{"Id":394911,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"13668059182"},{"Id":394912,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"13668059283"},{"Id":394913,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"13668059284"},{"Id":394914,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"13668059285"},{"Id":394915,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"13668059286"},{"Id":394916,"FormularyType":"OHP","DrugName":"APREPITANT PAK 125 & 80","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020006320","GenericName":"APREPITANT CAPSULE THERAPY PACK 80 & 125 MG","NDC":"13668059487"},{"Id":394917,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"13668059501"},{"Id":394918,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"13668059502"},{"Id":394919,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"13668063433"},{"Id":394920,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"13668063460"},{"Id":394921,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"13668063533"},{"Id":394922,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"13668063560"},{"Id":394923,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"13668063633"},{"Id":394924,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"13668063660"},{"Id":394925,"FormularyType":"OHP","DrugName":"SORAFENIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533060400320","GenericName":"SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"13668068212"},{"Id":394926,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"13668071157"},{"Id":394927,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"13668071191"},{"Id":394928,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"13668072005"},{"Id":394929,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"13668072090"},{"Id":394930,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"13668072105"},{"Id":394931,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"13668072190"},{"Id":394932,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"13668072205"},{"Id":394933,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"13668072290"},{"Id":394934,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"13668072305"},{"Id":394935,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"13668072330"},{"Id":394936,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"13668074633"},{"Id":394937,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"13668074660"},{"Id":394938,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"13668074733"},{"Id":394939,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"13668074760"},{"Id":394940,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"13668075442"},{"Id":394941,"FormularyType":"OHP","DrugName":"ERGOCALCIFER CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"13668075701"},{"Id":394942,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"13703010130"},{"Id":394943,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706350","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"13703010131"},{"Id":394944,"FormularyType":"OHP","DrugName":"ALLERGY TRAY KIT 27GX1/2\"","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706460","GenericName":"ALLERGY TRAY KIT 1 ML 27 X 1/2\"","NDC":"13703010133"},{"Id":394945,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"13703010150"},{"Id":394946,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"13703010151"},{"Id":394947,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"13703010160"},{"Id":394948,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706334","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"13703010161"},{"Id":394949,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"13703010210"},{"Id":394950,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"13703010211"},{"Id":394951,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"13703010270"},{"Id":394952,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"13703010271"},{"Id":394953,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906382","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 5/16\"","NDC":"13703010280"},{"Id":394954,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906382","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 5/16\"","NDC":"13703010281"},{"Id":394955,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906338","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 3/16\" (5 MM)","NDC":"13703010290"},{"Id":394956,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906338","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 3/16\" (5 MM)","NDC":"13703010291"},{"Id":394957,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"13703010300"},{"Id":394958,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"13703010301"},{"Id":394959,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"13703010310"},{"Id":394960,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"13703010311"},{"Id":394961,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"13703010320"},{"Id":394962,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"13703010321"},{"Id":394963,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"13703010330"},{"Id":394964,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"13703010331"},{"Id":394965,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"13703010340"},{"Id":394966,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"13703010341"},{"Id":394967,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"13703010350"},{"Id":394968,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"13703010351"},{"Id":394969,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"13703010360"},{"Id":394970,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"13703010361"},{"Id":394971,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"13703010370"},{"Id":394972,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"13703010371"},{"Id":394973,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"13703010380"},{"Id":394974,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"13703010381"},{"Id":394975,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"13703010390"},{"Id":394976,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"13703010391"},{"Id":394977,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"13703010540"},{"Id":394978,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"13703010541"},{"Id":394979,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056330","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1\"","NDC":"13703010550"},{"Id":394980,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056330","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1\"","NDC":"13703010551"},{"Id":394981,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"13703010560"},{"Id":394982,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"13703010561"},{"Id":394983,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106340","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1-1/2\"","NDC":"13703011060"},{"Id":394984,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106340","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1-1/2\"","NDC":"13703011061"},{"Id":394985,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"13703013010"},{"Id":394986,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"13703013011"},{"Id":394987,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"13703015220"},{"Id":394988,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"13703015221"},{"Id":394989,"FormularyType":"OHP","DrugName":"SYRINGE MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"13703015270"},{"Id":394990,"FormularyType":"OHP","DrugName":"SYRINGE MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"13703015271"},{"Id":394991,"FormularyType":"OHP","DrugName":"SYRINGE MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906355","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 3/16\" (5 MM)","NDC":"13703015290"},{"Id":394992,"FormularyType":"OHP","DrugName":"SYRINGE MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906355","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 3/16\" (5 MM)","NDC":"13703015291"},{"Id":394993,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"13703082010"},{"Id":394994,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"13703082011"},{"Id":394995,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"13703082030"},{"Id":394996,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"13703082031"},{"Id":394997,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"13703082090"},{"Id":394998,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"13703082091"},{"Id":394999,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"13703082310"},{"Id":395000,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"13703082311"},{"Id":395001,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"13703082330"},{"Id":395002,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"13703082331"},{"Id":395003,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"13703082390"},{"Id":395004,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"13703082391"},{"Id":395005,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"13703085010"},{"Id":395006,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"13703085021"},{"Id":395007,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"13703085031"},{"Id":395008,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 21G X 1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"13703085041"},{"Id":395009,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"13703085051"},{"Id":395010,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"13703085061"},{"Id":395011,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"13703085071"},{"Id":395012,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"13703085081"},{"Id":395013,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"13703085091"},{"Id":395014,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"13703085210"},{"Id":395015,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"13703085211"},{"Id":395016,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"13703085230"},{"Id":395017,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"13703085231"},{"Id":395018,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"13703085290"},{"Id":395019,"FormularyType":"OHP","DrugName":"EASYPOINT MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"13703085291"},{"Id":395020,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036307","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1\"","NDC":"13703085380"},{"Id":395021,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036307","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1\"","NDC":"13703085381"},{"Id":395022,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036310","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1-1/2\"","NDC":"13703085390"},{"Id":395023,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036310","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 18 X 1-1/2\"","NDC":"13703085391"},{"Id":395024,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"13733031315"},{"Id":395025,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"13733031316"},{"Id":395026,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"13733031317"},{"Id":395027,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"13733031318"},{"Id":395028,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"13733031374"},{"Id":395029,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD EX-THICK","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"13733037999"},{"Id":395030,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD EX-THICK","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"13733038002"},{"Id":395031,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"13733088582"},{"Id":395032,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"13733088583"},{"Id":395033,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"13733098364"},{"Id":395034,"FormularyType":"OHP","DrugName":"TRINATAL RX TAB 1","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000360","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG***","NDC":"13811000710"},{"Id":395035,"FormularyType":"OHP","DrugName":"COMPLETE NAT PAK DHA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78515022006315","GenericName":"*PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 200 PK**","NDC":"13811001030"},{"Id":395036,"FormularyType":"OHP","DrugName":"COMPLETENATE CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000530","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***","NDC":"13811001490"},{"Id":395037,"FormularyType":"OHP","DrugName":"ELITE-OB TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512010000352","GenericName":"*PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1.25 MG***","NDC":"13811002710"},{"Id":395038,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"13811020740"},{"Id":395039,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"13811020774"},{"Id":395040,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"13811029908"},{"Id":395041,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"13811030010"},{"Id":395042,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"13811030050"},{"Id":395043,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"13811030110"},{"Id":395044,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"13811030150"},{"Id":395045,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"13811030210"},{"Id":395046,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"13811030250"},{"Id":395047,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"13811030310"},{"Id":395048,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"13811030350"},{"Id":395049,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"13811030410"},{"Id":395050,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"13811030452"},{"Id":395051,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"13811030510"},{"Id":395052,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"13811030552"},{"Id":395053,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"13811030610"},{"Id":395054,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"13811030652"},{"Id":395055,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"13811030710"},{"Id":395056,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"13811030752"},{"Id":395057,"FormularyType":"OHP","DrugName":"TRIPHROCAPS CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000130","GenericName":"*B-COMPLEX W/ C & FOLIC ACID CAP 1 MG***","NDC":"13811052501"},{"Id":395058,"FormularyType":"OHP","DrugName":"FOLIVANE-OB CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512058000152","GenericName":"*PRENATAL W/O A W/FE FUM-FE POLY-FA CAP 85-1 MG***","NDC":"13811053530"},{"Id":395059,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 18MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100460","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG","NDC":"13811070610"},{"Id":395060,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 27MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100465","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","NDC":"13811070710"},{"Id":395061,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"13811070810"},{"Id":395062,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 54MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100480","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","NDC":"13811070910"},{"Id":395063,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"13811071910"},{"Id":395064,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"13874002003"},{"Id":395065,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"13874002037"},{"Id":395066,"FormularyType":"OHP","DrugName":"SE-NATAL 19 CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000530","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***","NDC":"13925011701"},{"Id":395067,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202040","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 5 MG/5ML (BASE EQUIV)","NDC":"13925016604"},{"Id":395068,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"14428000888"},{"Id":395069,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"14428000944"},{"Id":395070,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"14539067401"},{"Id":395071,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"14539067405"},{"Id":395072,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"14539067501"},{"Id":395073,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"14539067505"},{"Id":395074,"FormularyType":"OHP","DrugName":"QUICKVUE HOM KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"14613033967"},{"Id":395075,"FormularyType":"OHP","DrugName":"QUICKVUE HOM KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"14613033972"},{"Id":395076,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002070","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/50ML","NDC":"14789010705"},{"Id":395077,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002070","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/50ML","NDC":"14789010708"},{"Id":395078,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002055","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/50ML","NDC":"14789010805"},{"Id":395079,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002055","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/50ML","NDC":"14789010808"},{"Id":395080,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002060","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/100ML","NDC":"14789010810"},{"Id":395081,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002060","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/100ML","NDC":"14789010816"},{"Id":395082,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002050","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/100ML","NDC":"14789010910"},{"Id":395083,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002050","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/100ML","NDC":"14789010916"},{"Id":395084,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20/10ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"14789013605"},{"Id":395085,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20/10ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"14789013607"},{"Id":395086,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 40/20ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"14789013705"},{"Id":395087,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 40/20ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"14789013707"},{"Id":395088,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 500MG/ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102020","GenericName":"PROCAINAMIDE HCL INJ 500 MG/ML","NDC":"14789090002"},{"Id":395089,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 500MG/ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102020","GenericName":"PROCAINAMIDE HCL INJ 500 MG/ML","NDC":"14789090007"},{"Id":395090,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1000/10","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"14789090107"},{"Id":395091,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1000/10","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"14789090110"},{"Id":395092,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"15014091010"},{"Id":395093,"FormularyType":"OHP","DrugName":"IQIRVO TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR(PPAR) AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52780020000320","GenericName":"ELAFIBRANOR TAB 80 MG","NDC":"15054008001"},{"Id":395094,"FormularyType":"OHP","DrugName":"INCRELEX INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30160045002020","GenericName":"MECASERMIN INJ 40 MG/4ML (10 MG/ML)","NDC":"15054104005"},{"Id":395095,"FormularyType":"OHP","DrugName":"SB GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"15127000034"},{"Id":395096,"FormularyType":"OHP","DrugName":"SB GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"15127000035"},{"Id":395097,"FormularyType":"OHP","DrugName":"SB ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"15127000058"},{"Id":395098,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"15127000166"},{"Id":395099,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"15127000230"},{"Id":395100,"FormularyType":"OHP","DrugName":"CALCIUM + D TAB 600-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"15127000302"},{"Id":395101,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127000741"},{"Id":395102,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"15127000822"},{"Id":395103,"FormularyType":"OHP","DrugName":"SB ALCOHOL PAD PREP","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"15127000887"},{"Id":395104,"FormularyType":"OHP","DrugName":"SB GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"15127000888"},{"Id":395105,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000 MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"15127001069"},{"Id":395106,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"15127001105"},{"Id":395107,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"15127001145"},{"Id":395108,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127001192"},{"Id":395109,"FormularyType":"OHP","DrugName":"SB DOCUSATE TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"15127001346"},{"Id":395110,"FormularyType":"OHP","DrugName":"SB LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"15127001381"},{"Id":395111,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"15127001538"},{"Id":395112,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"15127001581"},{"Id":395113,"FormularyType":"OHP","DrugName":"CHLORPHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"15127001601"},{"Id":395114,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"15127001789"},{"Id":395115,"FormularyType":"OHP","DrugName":"SB ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"15127001801"},{"Id":395116,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"15127002185"},{"Id":395117,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"15127002246"},{"Id":395118,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"15127002247"},{"Id":395119,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"15127002248"},{"Id":395120,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"15127002294"},{"Id":395121,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"15127002423"},{"Id":395122,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"15127002424"},{"Id":395123,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"15127002432"},{"Id":395124,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127002472"},{"Id":395125,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127002473"},{"Id":395126,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127002474"},{"Id":395127,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127003630"},{"Id":395128,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"15127007208"},{"Id":395129,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"15127007224"},{"Id":395130,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"15127010001"},{"Id":395131,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL UNFLAVRD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"15127010002"},{"Id":395132,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL UNFLAVRD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"15127010003"},{"Id":395133,"FormularyType":"OHP","DrugName":"SB SENNA-LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"15127010501"},{"Id":395134,"FormularyType":"OHP","DrugName":"SB LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"15127010912"},{"Id":395135,"FormularyType":"OHP","DrugName":"SB GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"15127011025"},{"Id":395136,"FormularyType":"OHP","DrugName":"SB GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"15127011225"},{"Id":395137,"FormularyType":"OHP","DrugName":"SB GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"15127011250"},{"Id":395138,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"15127012020"},{"Id":395139,"FormularyType":"OHP","DrugName":"SB TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"15127012201"},{"Id":395140,"FormularyType":"OHP","DrugName":"SB TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"15127012205"},{"Id":395141,"FormularyType":"OHP","DrugName":"SB HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"15127012801"},{"Id":395142,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"15127013030"},{"Id":395143,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"15127013501"},{"Id":395144,"FormularyType":"OHP","DrugName":"SB BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"15127017807"},{"Id":395145,"FormularyType":"OHP","DrugName":"SB BISMUTH TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"15127018008"},{"Id":395146,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"15127020021"},{"Id":395147,"FormularyType":"OHP","DrugName":"SB ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"15127020524"},{"Id":395148,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"15127020737"},{"Id":395149,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"15127021024"},{"Id":395150,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"15127021124"},{"Id":395151,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"15127021296"},{"Id":395152,"FormularyType":"OHP","DrugName":"SB FIBER LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"15127021315"},{"Id":395153,"FormularyType":"OHP","DrugName":"SB FIBER LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"15127021320"},{"Id":395154,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022403"},{"Id":395155,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022404"},{"Id":395156,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ PLUS/VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022405"},{"Id":395157,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ PLUS/STR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022406"},{"Id":395158,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022407"},{"Id":395159,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ PLUS/STR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022408"},{"Id":395160,"FormularyType":"OHP","DrugName":"COMPLETE NUT LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"15127022424"},{"Id":395161,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"15127022894"},{"Id":395162,"FormularyType":"OHP","DrugName":"SB CHILD ASA CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"15127024136"},{"Id":395163,"FormularyType":"OHP","DrugName":"LICE TRTMNT LIQ 1%","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"15127024331"},{"Id":395164,"FormularyType":"OHP","DrugName":"SB SLEEP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"15127025816"},{"Id":395165,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"15127026212"},{"Id":395166,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127028106"},{"Id":395167,"FormularyType":"OHP","DrugName":"ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"15127028324"},{"Id":395168,"FormularyType":"OHP","DrugName":"ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"15127028348"},{"Id":395169,"FormularyType":"OHP","DrugName":"SB NON-ASA CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"15127028924"},{"Id":395170,"FormularyType":"OHP","DrugName":"SB DOCUSATE TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"15127029610"},{"Id":395171,"FormularyType":"OHP","DrugName":"NON-ASA JR TAB 160MG QM","DosageForm":"TBDP - Tablet Disintegrating","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010007220","GenericName":"ACETAMINOPHEN DISINTEGRATING TAB 160 MG","NDC":"15127029930"},{"Id":395172,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031201"},{"Id":395173,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031224"},{"Id":395174,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031225"},{"Id":395175,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031250"},{"Id":395176,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031301"},{"Id":395177,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031324"},{"Id":395178,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127031350"},{"Id":395179,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127033201"},{"Id":395180,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127033501"},{"Id":395181,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127033524"},{"Id":395182,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127033550"},{"Id":395183,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127036401"},{"Id":395184,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127036411"},{"Id":395185,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127036424"},{"Id":395186,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127036450"},{"Id":395187,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"15127037006"},{"Id":395188,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"15127037012"},{"Id":395189,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"15127037030"},{"Id":395190,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"15127040101"},{"Id":395191,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"15127040105"},{"Id":395192,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"15127040201"},{"Id":395193,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"15127040205"},{"Id":395194,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"15127040301"},{"Id":395195,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"15127040305"},{"Id":395196,"FormularyType":"OHP","DrugName":"ALLERGY MED LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"15127050404"},{"Id":395197,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"15127050961"},{"Id":395198,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"15127051004"},{"Id":395199,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127053001"},{"Id":395200,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127053024"},{"Id":395201,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"15127053050"},{"Id":395202,"FormularyType":"OHP","DrugName":"SB ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"15127054073"},{"Id":395203,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"15127068002"},{"Id":395204,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"15127068004"},{"Id":395205,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"15127071501"},{"Id":395206,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"15127071510"},{"Id":395207,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"15127071530"},{"Id":395208,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"15127071560"},{"Id":395209,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"15127071615"},{"Id":395210,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"15127071804"},{"Id":395211,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"15127071808"},{"Id":395212,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127072013"},{"Id":395213,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073005"},{"Id":395214,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073006"},{"Id":395215,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073021"},{"Id":395216,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073505"},{"Id":395217,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073508"},{"Id":395218,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073509"},{"Id":395219,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"15127073516"},{"Id":395220,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"15127073801"},{"Id":395221,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"15127073805"},{"Id":395222,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"15127073809"},{"Id":395223,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"15127073810"},{"Id":395224,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"15127073816"},{"Id":395225,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"15127073821"},{"Id":395226,"FormularyType":"OHP","DrugName":"SB ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"15127076008"},{"Id":395227,"FormularyType":"OHP","DrugName":"SB FIB LAX POW 33%","DosageForm":"POWD - Powder","Strength":"33","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102933","GenericName":"PSYLLIUM POWDER 33%","NDC":"15127080413"},{"Id":395228,"FormularyType":"OHP","DrugName":"SB FIB LAX POW 33%","DosageForm":"POWD - Powder","Strength":"33","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102933","GenericName":"PSYLLIUM POWDER 33%","NDC":"15127080419"},{"Id":395229,"FormularyType":"OHP","DrugName":"SB FIB LAX POW 30%","DosageForm":"POWD - Powder","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102930","GenericName":"PSYLLIUM POWDER 30%","NDC":"15127081513"},{"Id":395230,"FormularyType":"OHP","DrugName":"CHLORPHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"15127082109"},{"Id":395231,"FormularyType":"OHP","DrugName":"CHLD NON-ASA TAB 80MG QM","DosageForm":"TBDP - Tablet Disintegrating","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010007210","GenericName":"ACETAMINOPHEN DISINTEGRATING TAB 80 MG","NDC":"15127082830"},{"Id":395232,"FormularyType":"OHP","DrugName":"SB NON-ASA CHW 80MG FRT","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"15127083004"},{"Id":395233,"FormularyType":"OHP","DrugName":"SB NON-ASA CHW 80MG GRP","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"15127083204"},{"Id":395234,"FormularyType":"OHP","DrugName":"SB MILK MAGN SUS MINT","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"15127083573"},{"Id":395235,"FormularyType":"OHP","DrugName":"SB PAIN RELF TAB X-STR","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"15127085708"},{"Id":395236,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"15127089404"},{"Id":395237,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"15127089408"},{"Id":395238,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"15127089418"},{"Id":395239,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127090550"},{"Id":395240,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127090724"},{"Id":395241,"FormularyType":"OHP","DrugName":"SB IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"15127090750"},{"Id":395242,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"15127090804"},{"Id":395243,"FormularyType":"OHP","DrugName":"SB ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"15127090914"},{"Id":395244,"FormularyType":"OHP","DrugName":"SB ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"15127090930"},{"Id":395245,"FormularyType":"OHP","DrugName":"SB ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"15127090990"},{"Id":395246,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"15127096908"},{"Id":395247,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"15127096925"},{"Id":395248,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"15127096950"},{"Id":395249,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"15127097910"},{"Id":395250,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"15482023229"},{"Id":395251,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"15482023423"},{"Id":395252,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"15482023531"},{"Id":395253,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"15482026305"},{"Id":395254,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"15482026311"},{"Id":395255,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"15482026312"},{"Id":395256,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"15482026313"},{"Id":395257,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"15482026314"},{"Id":395258,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"15482026315"},{"Id":395259,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"15482026316"},{"Id":395260,"FormularyType":"OHP","DrugName":"ASSURE ID MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"15482027653"},{"Id":395261,"FormularyType":"OHP","DrugName":"ASSURE ID MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"15482027753"},{"Id":395262,"FormularyType":"OHP","DrugName":"ASSURE ID MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"15482027830"},{"Id":395263,"FormularyType":"OHP","DrugName":"INSUPEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"15832002001"},{"Id":395264,"FormularyType":"OHP","DrugName":"INSUPEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"15832002004"},{"Id":395265,"FormularyType":"OHP","DrugName":"INSUPEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"15832002006"},{"Id":395266,"FormularyType":"OHP","DrugName":"INSUPEN MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"15832002008"},{"Id":395267,"FormularyType":"OHP","DrugName":"PHARBECHLOR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"16103034608"},{"Id":395268,"FormularyType":"OHP","DrugName":"PHARBECHLOR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"16103034611"},{"Id":395269,"FormularyType":"OHP","DrugName":"PHARBEDRYL CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"16103034711"},{"Id":395270,"FormularyType":"OHP","DrugName":"PHARBEDRYL CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"16103034799"},{"Id":395271,"FormularyType":"OHP","DrugName":"PHARBEDRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"16103034808"},{"Id":395272,"FormularyType":"OHP","DrugName":"PHARBEDRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"16103034811"},{"Id":395273,"FormularyType":"OHP","DrugName":"PHARBEDRYL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"16103034899"},{"Id":395274,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"16103035609"},{"Id":395275,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"16103035611"},{"Id":395276,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"16103035708"},{"Id":395277,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"16103035711"},{"Id":395278,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"16103035799"},{"Id":395279,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"16103035908"},{"Id":395280,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"16103035911"},{"Id":395281,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"16103036007"},{"Id":395282,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"16103036008"},{"Id":395283,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"16103036011"},{"Id":395284,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"16103036099"},{"Id":395285,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"16103036107"},{"Id":395286,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"16103036108"},{"Id":395287,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"16103036111"},{"Id":395288,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"16103036199"},{"Id":395289,"FormularyType":"OHP","DrugName":"SENNA-TABS TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"16103036308"},{"Id":395290,"FormularyType":"OHP","DrugName":"SENNA-TABS TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"16103036311"},{"Id":395291,"FormularyType":"OHP","DrugName":"SENNA-TABS TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"16103036399"},{"Id":395292,"FormularyType":"OHP","DrugName":"SENNA/DSS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"16103036499"},{"Id":395293,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"16103036508"},{"Id":395294,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"16103036511"},{"Id":395295,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"16103036599"},{"Id":395296,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"16103036605"},{"Id":395297,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"16103036611"},{"Id":395298,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"16103036708"},{"Id":395299,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"16103036717"},{"Id":395300,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"1500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"16103036807"},{"Id":395301,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"1500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"16103036899"},{"Id":395302,"FormularyType":"OHP","DrugName":"CALCIUM TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"16103036907"},{"Id":395303,"FormularyType":"OHP","DrugName":"CALCIUM TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"16103036911"},{"Id":395304,"FormularyType":"OHP","DrugName":"CALCIUM TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"16103036999"},{"Id":395305,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"16103037807"},{"Id":395306,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"16103037811"},{"Id":395307,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"16103037899"},{"Id":395308,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"65","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"16103038208"},{"Id":395309,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"65","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"16103038211"},{"Id":395310,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"16103038408"},{"Id":395311,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"16103038411"},{"Id":395312,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"16103038499"},{"Id":395313,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"16103038708"},{"Id":395314,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"16103038711"},{"Id":395315,"FormularyType":"OHP","DrugName":"DOCUSATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"16103039908"},{"Id":395316,"FormularyType":"OHP","DrugName":"DOCUSATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"16103039911"},{"Id":395317,"FormularyType":"OHP","DrugName":"DOCUSATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"16103039999"},{"Id":395318,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"16103040299"},{"Id":395319,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"16103040706"},{"Id":395320,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"16103040708"},{"Id":395321,"FormularyType":"OHP","DrugName":"KIMONO MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169001003"},{"Id":395322,"FormularyType":"OHP","DrugName":"KIMONO MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169001012"},{"Id":395323,"FormularyType":"OHP","DrugName":"KIMONO MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169001013"},{"Id":395324,"FormularyType":"OHP","DrugName":"MAXX MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169002003"},{"Id":395325,"FormularyType":"OHP","DrugName":"MAXX MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169002013"},{"Id":395326,"FormularyType":"OHP","DrugName":"KIMONO PLUS MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169003003"},{"Id":395327,"FormularyType":"OHP","DrugName":"KIMONO MAXX MIS LG FLARE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169003012"},{"Id":395328,"FormularyType":"OHP","DrugName":"KIMONO PLUS MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169003013"},{"Id":395329,"FormularyType":"OHP","DrugName":"MAXX PLUS MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169004003"},{"Id":395330,"FormularyType":"OHP","DrugName":"MAXX PLUS MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169004012"},{"Id":395331,"FormularyType":"OHP","DrugName":"MAXX PLUS MIS SPERMICI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169004013"},{"Id":395332,"FormularyType":"OHP","DrugName":"KIMONO MICRO MIS THIN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"16169005003"},{"Id":395333,"FormularyType":"OHP","DrugName":"KIMONO MICRO MIS THIN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"16169005012"},{"Id":395334,"FormularyType":"OHP","DrugName":"KIMONO MICRO MIS THIN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"16169005013"},{"Id":395335,"FormularyType":"OHP","DrugName":"KIMONO MICRO MIS THIN +","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169006003"},{"Id":395336,"FormularyType":"OHP","DrugName":"KIMONO MICRO MIS THIN +","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169006012"},{"Id":395337,"FormularyType":"OHP","DrugName":"KIMONO MICRO MIS THIN PLS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169006013"},{"Id":395338,"FormularyType":"OHP","DrugName":"KIMONO MIS SENSATIO","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169007003"},{"Id":395339,"FormularyType":"OHP","DrugName":"KIMONO MIS SENSATIO","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169007012"},{"Id":395340,"FormularyType":"OHP","DrugName":"KIMONO MIS SENSATIO","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169007013"},{"Id":395341,"FormularyType":"OHP","DrugName":"KIMONO SENSA MIS PLUS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169008003"},{"Id":395342,"FormularyType":"OHP","DrugName":"KIMONO SENSA MIS PLUS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169008012"},{"Id":395343,"FormularyType":"OHP","DrugName":"KIMONO SENSA MIS PLUS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169008013"},{"Id":395344,"FormularyType":"OHP","DrugName":"KIMONO PS MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169011000"},{"Id":395345,"FormularyType":"OHP","DrugName":"KIMONO SPEC MIS","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169011012"},{"Id":395346,"FormularyType":"OHP","DrugName":"KIMONO COLOR MIS","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169013012"},{"Id":395347,"FormularyType":"OHP","DrugName":"KIMONO PS MIS PLUS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"16169021000"},{"Id":395348,"FormularyType":"OHP","DrugName":"TODAY SPONGE MIS","DosageForm":"MISC - Miscellaneous","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"SPERMICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55300010006320","GenericName":"NONOXYNOL-9 VAGINAL SPONGE 1000 MG","NDC":"16169040403"},{"Id":395349,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"16477034001"},{"Id":395350,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"16477034003"},{"Id":395351,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"16477034007"},{"Id":395352,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.375 ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0.375","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107420","GenericName":"HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","NDC":"16477073801"},{"Id":395353,"FormularyType":"OHP","DrugName":"CLINITEST KIT SELF-TST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"16490002573"},{"Id":395354,"FormularyType":"OHP","DrugName":"CLINITEST KIT SELF-TST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"16490002574"},{"Id":395355,"FormularyType":"OHP","DrugName":"CLINITEST KIT SELF-TST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"16490002594"},{"Id":395356,"FormularyType":"OHP","DrugName":"CLINITEST KIT SELF-TST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"16490002597"},{"Id":395357,"FormularyType":"OHP","DrugName":"FLINTSTONES CHW MY FIRST","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"16500007814"},{"Id":395358,"FormularyType":"OHP","DrugName":"FLINTSTONES CHW MY FIRST","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"16500007818"},{"Id":395359,"FormularyType":"OHP","DrugName":"ONE A DAY CAP PRENATAL","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516015000130","GenericName":"*PRENATAL MV & MIN W/FE CARBONYL-FA-DHA CAP 27-0.8-200 MG**","NDC":"16500055817"},{"Id":395360,"FormularyType":"OHP","DrugName":"ONE A DAY CAP PRENATAL","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516015000130","GenericName":"*PRENATAL MV & MIN W/FE CARBONYL-FA-DHA CAP 27-0.8-200 MG**","NDC":"16500056010"},{"Id":395361,"FormularyType":"OHP","DrugName":"ONE A DAY CAP PRENATAL","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516015000130","GenericName":"*PRENATAL MV & MIN W/FE CARBONYL-FA-DHA CAP 27-0.8-200 MG**","NDC":"16500056390"},{"Id":395362,"FormularyType":"OHP","DrugName":"ONE A DAY CHW PRENATAL","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000530","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.4-25 MG***","NDC":"16500056870"},{"Id":395363,"FormularyType":"OHP","DrugName":"ONE A DAY CHW PRENATAL","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000530","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.4-25 MG***","NDC":"16500056871"},{"Id":395364,"FormularyType":"OHP","DrugName":"PEDIA SMART POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"16514088101"},{"Id":395365,"FormularyType":"OHP","DrugName":"PEDIA SMART POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"16514088103"},{"Id":395366,"FormularyType":"OHP","DrugName":"PEDIASMART POW PEA PROT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"16514088123"},{"Id":395367,"FormularyType":"OHP","DrugName":"PEDIA SMART POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"16514088201"},{"Id":395368,"FormularyType":"OHP","DrugName":"PEDIA VANCE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"16514091470"},{"Id":395369,"FormularyType":"OHP","DrugName":"PEDIA VANCE SOL APPLE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"16514092460"},{"Id":395370,"FormularyType":"OHP","DrugName":"ST JOSEPH TAB LOW 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"16526001001"},{"Id":395371,"FormularyType":"OHP","DrugName":"ST JOSEPH TAB LOW 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"16526001002"},{"Id":395372,"FormularyType":"OHP","DrugName":"ST JOSEPH TAB LOW 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"16526001021"},{"Id":395373,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"16526001022"},{"Id":395374,"FormularyType":"OHP","DrugName":"ST JOSEPH CHW LOW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"16526001075"},{"Id":395375,"FormularyType":"OHP","DrugName":"XMET XCYS POW MAXAMAID","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"16533063123"},{"Id":395376,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"16571010009"},{"Id":395377,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"16571010010"},{"Id":395378,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"16571011201"},{"Id":395379,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"16571011250"},{"Id":395380,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"16571011301"},{"Id":395381,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"16571011350"},{"Id":395382,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"16571011401"},{"Id":395383,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"16571011410"},{"Id":395384,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"16571011450"},{"Id":395385,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"16571011501"},{"Id":395386,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"16571011510"},{"Id":395387,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"16571011550"},{"Id":395388,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"16571011701"},{"Id":395389,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"16571011750"},{"Id":395390,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"16571012606"},{"Id":395391,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"16571012706"},{"Id":395392,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"16571012750"},{"Id":395393,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"16571012815"},{"Id":395394,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"16571012848"},{"Id":395395,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"16571012852"},{"Id":395396,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"16571013412"},{"Id":395397,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"16571013448"},{"Id":395398,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"16571013609"},{"Id":395399,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"16571013610"},{"Id":395400,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"16571013650"},{"Id":395401,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16571013709"},{"Id":395402,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16571013710"},{"Id":395403,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16571013750"},{"Id":395404,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16571013809"},{"Id":395405,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16571013810"},{"Id":395406,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16571013850"},{"Id":395407,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"16571013909"},{"Id":395408,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"16571013910"},{"Id":395409,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"16571013950"},{"Id":395410,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902107210","GenericName":"CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 10-100 MG","NDC":"16571015701"},{"Id":395411,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902107220","GenericName":"CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-100 MG","NDC":"16571015801"},{"Id":395412,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902107230","GenericName":"CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-250 MG","NDC":"16571015901"},{"Id":395413,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"16571016501"},{"Id":395414,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"16571016601"},{"Id":395415,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"16571016701"},{"Id":395416,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"16571016801"},{"Id":395417,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"16571016901"},{"Id":395418,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"16571017101"},{"Id":395419,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"16571017110"},{"Id":395420,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"16571017150"},{"Id":395421,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"16571017201"},{"Id":395422,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"16571017210"},{"Id":395423,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"16571017250"},{"Id":395424,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"16571017303"},{"Id":395425,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"16571017309"},{"Id":395426,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"16571017403"},{"Id":395427,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"16571017409"},{"Id":395428,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"16571020106"},{"Id":395429,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"16571020110"},{"Id":395430,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"16571020111"},{"Id":395431,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"16571020150"},{"Id":395432,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"16571020206"},{"Id":395433,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"16571020210"},{"Id":395434,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"16571020211"},{"Id":395435,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 25MG DR","DosageForm":"TBEC - Tablet DR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200610","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG","NDC":"16571020310"},{"Id":395436,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"16571022601"},{"Id":395437,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"16571022650"},{"Id":395438,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"16571024503"},{"Id":395439,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"16571024603"},{"Id":395440,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"16571025901"},{"Id":395441,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"16571025910"},{"Id":395442,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"16571026001"},{"Id":395443,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"16571026010"},{"Id":395444,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100310","GenericName":"CETIRIZINE HCL TAB 5 MG","NDC":"16571040110"},{"Id":395445,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"16571040210"},{"Id":395446,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"16571040250"},{"Id":395447,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"16571041110"},{"Id":395448,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"16571041210"},{"Id":395449,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"16571041250"},{"Id":395450,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"16571041305"},{"Id":395451,"FormularyType":"OHP","DrugName":"SELEGILINE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100120","GenericName":"SELEGILINE HCL CAP 5 MG","NDC":"16571065906"},{"Id":395452,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"16571066001"},{"Id":395453,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"16571066050"},{"Id":395454,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"16571066101"},{"Id":395455,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"16571066110"},{"Id":395456,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"16571066401"},{"Id":395457,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"16571066450"},{"Id":395458,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"16571066501"},{"Id":395459,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"16571066550"},{"Id":395460,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"16571066701"},{"Id":395461,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"16571066710"},{"Id":395462,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"16571066801"},{"Id":395463,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"16571066901"},{"Id":395464,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"16571066950"},{"Id":395465,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"16571067050"},{"Id":395466,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"16571067101"},{"Id":395467,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"16571067110"},{"Id":395468,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"16571067201"},{"Id":395469,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"16571067250"},{"Id":395470,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"16571067301"},{"Id":395471,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"16571067310"},{"Id":395472,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"16571067401"},{"Id":395473,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"16571067450"},{"Id":395474,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"16571067516"},{"Id":395475,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"16571067701"},{"Id":395476,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"16571067801"},{"Id":395477,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"16571067901"},{"Id":395478,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"16571068001"},{"Id":395479,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"16571068101"},{"Id":395480,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"16571068201"},{"Id":395481,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"16571068607"},{"Id":395482,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE TRO 10MG","DosageForm":"TROC - Troche","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100020004805","GenericName":"CLOTRIMAZOLE TROCHE 10 MG","NDC":"16571068614"},{"Id":395483,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"16571071601"},{"Id":395484,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"16571071610"},{"Id":395485,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"16571071650"},{"Id":395486,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000307","GenericName":"CHLORZOXAZONE TAB 375 MG","NDC":"16571072501"},{"Id":395487,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"16571072601"},{"Id":395488,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000320","GenericName":"CHLORZOXAZONE TAB 750 MG","NDC":"16571072701"},{"Id":395489,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"16571073521"},{"Id":395490,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"16571073528"},{"Id":395491,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"16571075809"},{"Id":395492,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"16571075909"},{"Id":395493,"FormularyType":"OHP","DrugName":"LEVOCARNITIN TAB 330MG","DosageForm":"TABS - Tablet","Strength":"330","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045100330","GenericName":"LEVOCARNITINE TAB 330 MG","NDC":"16571076209"},{"Id":395494,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"16571077301"},{"Id":395495,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"16571077350"},{"Id":395496,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"16571077401"},{"Id":395497,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"16571077450"},{"Id":395498,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"16571077501"},{"Id":395499,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"16571077550"},{"Id":395500,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"16571077803"},{"Id":395501,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"16571077809"},{"Id":395502,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"16571077810"},{"Id":395503,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"16571077850"},{"Id":395504,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"16571077903"},{"Id":395505,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"16571077909"},{"Id":395506,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"16571077910"},{"Id":395507,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"16571077950"},{"Id":395508,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"16571078201"},{"Id":395509,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"16571078210"},{"Id":395510,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"16571078250"},{"Id":395511,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"16571078310"},{"Id":395512,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"16571078350"},{"Id":395513,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"16571078406"},{"Id":395514,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"16571078450"},{"Id":395515,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"16571078850"},{"Id":395516,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"16571080316"},{"Id":395517,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"16571080413"},{"Id":395518,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"16571080501"},{"Id":395519,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"16571080510"},{"Id":395520,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"16571080606"},{"Id":395521,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"16571081320"},{"Id":395522,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"16571081641"},{"Id":395523,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"16571081651"},{"Id":395524,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"16571081741"},{"Id":395525,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"16571081751"},{"Id":395526,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"16571081841"},{"Id":395527,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"16571081851"},{"Id":395528,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"16571081941"},{"Id":395529,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"16571081951"},{"Id":395530,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"16571082041"},{"Id":395531,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"16571082051"},{"Id":395532,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"16571082151"},{"Id":395533,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"16571082201"},{"Id":395534,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"16571082203"},{"Id":395535,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"16571082230"},{"Id":395536,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"16571082401"},{"Id":395537,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"16571082410"},{"Id":395538,"FormularyType":"OHP","DrugName":"CAPTOPR/HCTZ TAB 25-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802250310","GenericName":"CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG","NDC":"16571082709"},{"Id":395539,"FormularyType":"OHP","DrugName":"CAPTOPR/HCTZ TAB 25-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802250320","GenericName":"CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"16571082809"},{"Id":395540,"FormularyType":"OHP","DrugName":"CAPTOPR/HCTZ TAB 50-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802250330","GenericName":"CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-15 MG","NDC":"16571082909"},{"Id":395541,"FormularyType":"OHP","DrugName":"CAPTOPR/HCTZ TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802250340","GenericName":"CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","NDC":"16571083009"},{"Id":395542,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"16571083101"},{"Id":395543,"FormularyType":"OHP","DrugName":"PROBENECID TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"URICOSURICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68100010000310","GenericName":"PROBENECID TAB 500 MG","NDC":"16571083110"},{"Id":395544,"FormularyType":"OHP","DrugName":"PROBEN/COLCH TAB 500-0.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENT COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68990002100310","GenericName":"COLCHICINE W/ PROBENECID TAB 0.5-500 MG","NDC":"16571083201"},{"Id":395545,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"16571083316"},{"Id":395546,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"16571083401"},{"Id":395547,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"16571083450"},{"Id":395548,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"16571083501"},{"Id":395549,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"16571084201"},{"Id":395550,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"16571084250"},{"Id":395551,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"16571084301"},{"Id":395552,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"16571084350"},{"Id":395553,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"16571085601"},{"Id":395554,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"16571085650"},{"Id":395555,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"16571086125"},{"Id":395556,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"16571086401"},{"Id":395557,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"16571086501"},{"Id":395558,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"16571086701"},{"Id":395559,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"16571086710"},{"Id":395560,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"16571086750"},{"Id":395561,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"16571086801"},{"Id":395562,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"16571086810"},{"Id":395563,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"16571086850"},{"Id":395564,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"16571086901"},{"Id":395565,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"16571086910"},{"Id":395566,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"16571086950"},{"Id":395567,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"16571087201"},{"Id":395568,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"16571087301"},{"Id":395569,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000303","GenericName":"INDAPAMIDE TAB 1.25 MG","NDC":"16571087501"},{"Id":395570,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000305","GenericName":"INDAPAMIDE TAB 2.5 MG","NDC":"16571087601"},{"Id":395571,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"16571088042"},{"Id":395572,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"16571088101"},{"Id":395573,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"16571088110"},{"Id":395574,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"16571088205"},{"Id":395575,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16571088309"},{"Id":395576,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16571088310"},{"Id":395577,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000307","GenericName":"ALLOPURINOL TAB 200 MG","NDC":"16571088409"},{"Id":395578,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"16571088509"},{"Id":395579,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"16571088550"},{"Id":395580,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"16714000601"},{"Id":395581,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"16714000610"},{"Id":395582,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"16714000701"},{"Id":395583,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"16714000801"},{"Id":395584,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"16714000901"},{"Id":395585,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"16714001001"},{"Id":395586,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"16714001601"},{"Id":395587,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"16714001610"},{"Id":395588,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"16714002601"},{"Id":395589,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"16714002610"},{"Id":395590,"FormularyType":"OHP","DrugName":"ETONOGESTREL MIS ETHY EST","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"16714002901"},{"Id":395591,"FormularyType":"OHP","DrugName":"ETONOGESTREL MIS ETHY EST","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"16714002903"},{"Id":395592,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"16714003401"},{"Id":395593,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"16714003402"},{"Id":395594,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"16714003501"},{"Id":395595,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"16714003502"},{"Id":395596,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"16714003601"},{"Id":395597,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"16714003610"},{"Id":395598,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"16714003901"},{"Id":395599,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"16714003902"},{"Id":395600,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"16714004601"},{"Id":395601,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"16714004610"},{"Id":395602,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"16714005201"},{"Id":395603,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"16714005202"},{"Id":395604,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"16714005203"},{"Id":395605,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"16714005204"},{"Id":395606,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"16714005210"},{"Id":395607,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"16714005211"},{"Id":395608,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"16714005601"},{"Id":395609,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"16714005610"},{"Id":395610,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"16714005901"},{"Id":395611,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"16714006001"},{"Id":395612,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"16714006301"},{"Id":395613,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"16714006401"},{"Id":395614,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"16714006501"},{"Id":395615,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"16714006601"},{"Id":395616,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"16714006610"},{"Id":395617,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"16714007104"},{"Id":395618,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"16714007106"},{"Id":395619,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"16714007204"},{"Id":395620,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"16714007205"},{"Id":395621,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"16714008110"},{"Id":395622,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"16714008111"},{"Id":395623,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"16714008210"},{"Id":395624,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"16714008211"},{"Id":395625,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"16714008212"},{"Id":395626,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"16714008310"},{"Id":395627,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"16714008311"},{"Id":395628,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"16714008701"},{"Id":395629,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"16714009801"},{"Id":395630,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"16714009901"},{"Id":395631,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"16714010001"},{"Id":395632,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"16714010102"},{"Id":395633,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"16714010105"},{"Id":395634,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"16714011001"},{"Id":395635,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"16714011002"},{"Id":395636,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"16714012301"},{"Id":395637,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"16714012302"},{"Id":395638,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"16714012303"},{"Id":395639,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"16714012801"},{"Id":395640,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"16714012901"},{"Id":395641,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"16714013001"},{"Id":395642,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"16714013025"},{"Id":395643,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 200/5ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"16714014001"},{"Id":395644,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 400/10ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"16714015001"},{"Id":395645,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"16714015701"},{"Id":395646,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"16714015801"},{"Id":395647,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"16714015901"},{"Id":395648,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"16714016001"},{"Id":395649,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"16714016101"},{"Id":395650,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"16714016102"},{"Id":395651,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"16714016601"},{"Id":395652,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"16714016701"},{"Id":395653,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"16714016801"},{"Id":395654,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"16714017101"},{"Id":395655,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"16714017201"},{"Id":395656,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"16714017202"},{"Id":395657,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"16714017301"},{"Id":395658,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"16714017303"},{"Id":395659,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16714017401"},{"Id":395660,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16714017402"},{"Id":395661,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16714017403"},{"Id":395662,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16714017501"},{"Id":395663,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16714017502"},{"Id":395664,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16714017503"},{"Id":395665,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"16714017601"},{"Id":395666,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"16714017602"},{"Id":395667,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"16714017603"},{"Id":395668,"FormularyType":"OHP","DrugName":"FLUOROURACIL CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030003730","GenericName":"FLUOROURACIL CREAM 5%","NDC":"16714017801"},{"Id":395669,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000310","GenericName":"SIROLIMUS TAB 0.5 MG","NDC":"16714018701"},{"Id":395670,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"16714018801"},{"Id":395671,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000330","GenericName":"SIROLIMUS TAB 2 MG","NDC":"16714018901"},{"Id":395672,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"16714019801"},{"Id":395673,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"16714019901"},{"Id":395674,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"16714020010"},{"Id":395675,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"16714020030"},{"Id":395676,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"16714020110"},{"Id":395677,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"16714020130"},{"Id":395678,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"16714021301"},{"Id":395679,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"16714021302"},{"Id":395680,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"16714021303"},{"Id":395681,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"16714022401"},{"Id":395682,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"16714022402"},{"Id":395683,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"16714022403"},{"Id":395684,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"16714022501"},{"Id":395685,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"16714022502"},{"Id":395686,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"16714022504"},{"Id":395687,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"16714022601"},{"Id":395688,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"16714022602"},{"Id":395689,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"16714022604"},{"Id":395690,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"16714023401"},{"Id":395691,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"16714023402"},{"Id":395692,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"16714023501"},{"Id":395693,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"16714023502"},{"Id":395694,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"16714024501"},{"Id":395695,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"16714024530"},{"Id":395696,"FormularyType":"OHP","DrugName":"CLINDAMYCIN LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104105","GenericName":"CLINDAMYCIN PHOSPHATE LOTION 1%","NDC":"16714024601"},{"Id":395697,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"16714026701"},{"Id":395698,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"16714026702"},{"Id":395699,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"16714026703"},{"Id":395700,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.5%","DosageForm":"OINT - Ointment","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104215","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.5%","NDC":"16714026801"},{"Id":395701,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"16714027001"},{"Id":395702,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"16714027002"},{"Id":395703,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"16714027601"},{"Id":395704,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"16714027602"},{"Id":395705,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"16714027603"},{"Id":395706,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"16714029201"},{"Id":395707,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"16714029202"},{"Id":395708,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"16714029203"},{"Id":395709,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"16714029301"},{"Id":395710,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"16714029302"},{"Id":395711,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"16714029303"},{"Id":395712,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"16714029401"},{"Id":395713,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"16714029402"},{"Id":395714,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"16714029403"},{"Id":395715,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 250-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200310","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 250-125 MG","NDC":"16714029501"},{"Id":395716,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"16714029601"},{"Id":395717,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"16714029701"},{"Id":395718,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"16714029702"},{"Id":395719,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"16714029801"},{"Id":395720,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"16714029802"},{"Id":395721,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"16714029902"},{"Id":395722,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"16714029903"},{"Id":395723,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"16714029904"},{"Id":395724,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"16714031001"},{"Id":395725,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"16714033001"},{"Id":395726,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"16714033002"},{"Id":395727,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"16714033201"},{"Id":395728,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"16714033202"},{"Id":395729,"FormularyType":"OHP","DrugName":"LEVONEST TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002100310","GenericName":"LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","NDC":"16714034001"},{"Id":395730,"FormularyType":"OHP","DrugName":"LEVONEST TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002100310","GenericName":"LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","NDC":"16714034004"},{"Id":395731,"FormularyType":"OHP","DrugName":"DASETTA TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"16714034601"},{"Id":395732,"FormularyType":"OHP","DrugName":"DASETTA TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"16714034604"},{"Id":395733,"FormularyType":"OHP","DrugName":"PHILITH TAB 0.4-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"16714034701"},{"Id":395734,"FormularyType":"OHP","DrugName":"PHILITH TAB 0.4-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"16714034704"},{"Id":395735,"FormularyType":"OHP","DrugName":"DASETTA TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"16714034801"},{"Id":395736,"FormularyType":"OHP","DrugName":"DASETTA TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"16714034804"},{"Id":395737,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"16714035801"},{"Id":395738,"FormularyType":"OHP","DrugName":"FALMINA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"16714035901"},{"Id":395739,"FormularyType":"OHP","DrugName":"FALMINA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"16714035903"},{"Id":395740,"FormularyType":"OHP","DrugName":"FALMINA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"16714035904"},{"Id":395741,"FormularyType":"OHP","DrugName":"MONO-LINYAH TAB 0.25-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"16714036001"},{"Id":395742,"FormularyType":"OHP","DrugName":"MONO-LINYAH TAB 0.25-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"16714036004"},{"Id":395743,"FormularyType":"OHP","DrugName":"TRI-LINYAH TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"16714036301"},{"Id":395744,"FormularyType":"OHP","DrugName":"TRI-LINYAH TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"16714036304"},{"Id":395745,"FormularyType":"OHP","DrugName":"ELINEST TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"16714036501"},{"Id":395746,"FormularyType":"OHP","DrugName":"ELINEST TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"16714036504"},{"Id":395747,"FormularyType":"OHP","DrugName":"SETLAKIN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"16714036601"},{"Id":395748,"FormularyType":"OHP","DrugName":"SETLAKIN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"16714036603"},{"Id":395749,"FormularyType":"OHP","DrugName":"WERA TAB 0.5/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500310","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","NDC":"16714037001"},{"Id":395750,"FormularyType":"OHP","DrugName":"WERA TAB 0.5/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500310","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","NDC":"16714037003"},{"Id":395751,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"16714038801"},{"Id":395752,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"16714038802"},{"Id":395753,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001910","GenericName":"CEFADROXIL FOR SUSP 250 MG/5ML","NDC":"16714038901"},{"Id":395754,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"16714039001"},{"Id":395755,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"16714039002"},{"Id":395756,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100320","GenericName":"CEFPODOXIME PROXETIL TAB 100 MG","NDC":"16714039401"},{"Id":395757,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100330","GenericName":"CEFPODOXIME PROXETIL TAB 200 MG","NDC":"16714039501"},{"Id":395758,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"16714039602"},{"Id":395759,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"16714039603"},{"Id":395760,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"16714039701"},{"Id":395761,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"16714039702"},{"Id":395762,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"16714039703"},{"Id":395763,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"16714039801"},{"Id":395764,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"16714039901"},{"Id":395765,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"16714040001"},{"Id":395766,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"16714040002"},{"Id":395767,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"16714040101"},{"Id":395768,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"16714040102"},{"Id":395769,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 50MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"50","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101920","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML","NDC":"16714040201"},{"Id":395770,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 50MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"50","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101920","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML","NDC":"16714040202"},{"Id":395771,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101930","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","NDC":"16714040301"},{"Id":395772,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101930","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","NDC":"16714040302"},{"Id":395773,"FormularyType":"OHP","DrugName":"PIMTREA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"16714040401"},{"Id":395774,"FormularyType":"OHP","DrugName":"PIMTREA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"16714040404"},{"Id":395775,"FormularyType":"OHP","DrugName":"LARIN FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"16714040501"},{"Id":395776,"FormularyType":"OHP","DrugName":"LARIN FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"16714040504"},{"Id":395777,"FormularyType":"OHP","DrugName":"LARIN FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"16714040601"},{"Id":395778,"FormularyType":"OHP","DrugName":"LARIN FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"16714040604"},{"Id":395779,"FormularyType":"OHP","DrugName":"LARIN TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"16714040701"},{"Id":395780,"FormularyType":"OHP","DrugName":"LARIN TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"16714040703"},{"Id":395781,"FormularyType":"OHP","DrugName":"LARIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"16714040801"},{"Id":395782,"FormularyType":"OHP","DrugName":"LARIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"16714040803"},{"Id":395783,"FormularyType":"OHP","DrugName":"LARIN 24 TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"16714041601"},{"Id":395784,"FormularyType":"OHP","DrugName":"LARIN 24 TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"16714041603"},{"Id":395785,"FormularyType":"OHP","DrugName":"DEBLITANE TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"16714044001"},{"Id":395786,"FormularyType":"OHP","DrugName":"DEBLITANE TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"16714044004"},{"Id":395787,"FormularyType":"OHP","DrugName":"SHAROBEL TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"16714044101"},{"Id":395788,"FormularyType":"OHP","DrugName":"SHAROBEL TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"16714044104"},{"Id":395789,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"16714044201"},{"Id":395790,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"16714044202"},{"Id":395791,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"16714044301"},{"Id":395792,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"16714044302"},{"Id":395793,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"16714044401"},{"Id":395794,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"16714044402"},{"Id":395795,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"16714044501"},{"Id":395796,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"16714044502"},{"Id":395797,"FormularyType":"OHP","DrugName":"JULEBER TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"16714046401"},{"Id":395798,"FormularyType":"OHP","DrugName":"JULEBER TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"16714046404"},{"Id":395799,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 250-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200310","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 250-125 MG","NDC":"16714047601"},{"Id":395800,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"16714048301"},{"Id":395801,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"16714048302"},{"Id":395802,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE 1-0.05%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"16714049601"},{"Id":395803,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE 1-0.05%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"16714049602"},{"Id":395804,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"16714052301"},{"Id":395805,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"16714052302"},{"Id":395806,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"16714052401"},{"Id":395807,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"16714052402"},{"Id":395808,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"16714052501"},{"Id":395809,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"16714052502"},{"Id":395810,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"16714052601"},{"Id":395811,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"16714052901"},{"Id":395812,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"16714052902"},{"Id":395813,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"16714053001"},{"Id":395814,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"16714053002"},{"Id":395815,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"16714053401"},{"Id":395816,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"16714053501"},{"Id":395817,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"16714053701"},{"Id":395818,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"16714053702"},{"Id":395819,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"16714054801"},{"Id":395820,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"16714054901"},{"Id":395821,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"16714055001"},{"Id":395822,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"16714055201"},{"Id":395823,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"16714055301"},{"Id":395824,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"16714055401"},{"Id":395825,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"16714055501"},{"Id":395826,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"16714055701"},{"Id":395827,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"16714055801"},{"Id":395828,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"16714055802"},{"Id":395829,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"16714055901"},{"Id":395830,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"16714055902"},{"Id":395831,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"16714056001"},{"Id":395832,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"16714056002"},{"Id":395833,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"16714057001"},{"Id":395834,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"16714057002"},{"Id":395835,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16714057601"},{"Id":395836,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16714057602"},{"Id":395837,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16714057603"},{"Id":395838,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16714057604"},{"Id":395839,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"16714057701"},{"Id":395840,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"16714057702"},{"Id":395841,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"16714062101"},{"Id":395842,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"16714062102"},{"Id":395843,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"16714062201"},{"Id":395844,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"16714062202"},{"Id":395845,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"16714062801"},{"Id":395846,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"16714063101"},{"Id":395847,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"16714063102"},{"Id":395848,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"16714063201"},{"Id":395849,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"16714063202"},{"Id":395850,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"16714063301"},{"Id":395851,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"16714063302"},{"Id":395852,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"16714063401"},{"Id":395853,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"16714063402"},{"Id":395854,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"16714063403"},{"Id":395855,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"16714063601"},{"Id":395856,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"16714064301"},{"Id":395857,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"16714064501"},{"Id":395858,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"16714064502"},{"Id":395859,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"16714064503"},{"Id":395860,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"16714064601"},{"Id":395861,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"16714064602"},{"Id":395862,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"16714064603"},{"Id":395863,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"16714064701"},{"Id":395864,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"16714064702"},{"Id":395865,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"16714064703"},{"Id":395866,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"16714066101"},{"Id":395867,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"16714066102"},{"Id":395868,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"16714066201"},{"Id":395869,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"16714066202"},{"Id":395870,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"16714066301"},{"Id":395871,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"16714066302"},{"Id":395872,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"16714067102"},{"Id":395873,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"16714067601"},{"Id":395874,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"16714067701"},{"Id":395875,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"16714067801"},{"Id":395876,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"16714067901"},{"Id":395877,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"16714068101"},{"Id":395878,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"16714068102"},{"Id":395879,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"16714068201"},{"Id":395880,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"16714068202"},{"Id":395881,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"16714068203"},{"Id":395882,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"16714068301"},{"Id":395883,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"16714068302"},{"Id":395884,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"16714068303"},{"Id":395885,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"16714068401"},{"Id":395886,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"16714068402"},{"Id":395887,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"16714068403"},{"Id":395888,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"16714068501"},{"Id":395889,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"16714068502"},{"Id":395890,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"16714068503"},{"Id":395891,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"16714069101"},{"Id":395892,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"16714069102"},{"Id":395893,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"16714069210"},{"Id":395894,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"16714069211"},{"Id":395895,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"16714069301"},{"Id":395896,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"16714069302"},{"Id":395897,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"16714069401"},{"Id":395898,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 10MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001910","GenericName":"FLUCONAZOLE FOR SUSP 10 MG/ML","NDC":"16714069501"},{"Id":395899,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001940","GenericName":"FLUCONAZOLE FOR SUSP 40 MG/ML","NDC":"16714069601"},{"Id":395900,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"16714069703"},{"Id":395901,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"16714069803"},{"Id":395902,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"16714071401"},{"Id":395903,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"16714071501"},{"Id":395904,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"16714071502"},{"Id":395905,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"16714071503"},{"Id":395906,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"16714071701"},{"Id":395907,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"16714071801"},{"Id":395908,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"16714073201"},{"Id":395909,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"16714073202"},{"Id":395910,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"16714073301"},{"Id":395911,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"16714073302"},{"Id":395912,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"16714074302"},{"Id":395913,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN CRE 0.005%","DosageForm":"CREA - Cream","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025003710","GenericName":"CALCIPOTRIENE CREAM 0.005%","NDC":"16714076301"},{"Id":395914,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN CRE 0.005%","DosageForm":"CREA - Cream","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025003710","GenericName":"CALCIPOTRIENE CREAM 0.005%","NDC":"16714076302"},{"Id":395915,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"16714077501"},{"Id":395916,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"16714077502"},{"Id":395917,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"16714079501"},{"Id":395918,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"16714079502"},{"Id":395919,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"16714079601"},{"Id":395920,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"16714079701"},{"Id":395921,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"16714079801"},{"Id":395922,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"16714079901"},{"Id":395923,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"16714079902"},{"Id":395924,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"16714079903"},{"Id":395925,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"16714079904"},{"Id":395926,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"16714080501"},{"Id":395927,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"16714080801"},{"Id":395928,"FormularyType":"OHP","DrugName":"NEW DAY TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"16714080901"},{"Id":395929,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"16714081301"},{"Id":395930,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"16714081302"},{"Id":395931,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"16714081303"},{"Id":395932,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"16714081401"},{"Id":395933,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"16714082001"},{"Id":395934,"FormularyType":"OHP","DrugName":"BUDESONIDE CAP 3MG DR","DosageForm":"CPEP - Capsule DR Part","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100012006720","GenericName":"BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","NDC":"16714082901"},{"Id":395935,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"16714088701"},{"Id":395936,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"16714088801"},{"Id":395937,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"16714088901"},{"Id":395938,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"16714088910"},{"Id":395939,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 2.5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007505","GenericName":"GLIPIZIDE TAB ER 24HR 2.5 MG","NDC":"16714089401"},{"Id":395940,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"16714089501"},{"Id":395941,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"16714089502"},{"Id":395942,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"16714089601"},{"Id":395943,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"16714089602"},{"Id":395944,"FormularyType":"OHP","DrugName":"PERMETHRIN CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035003720","GenericName":"PERMETHRIN CREAM 5%","NDC":"16714089701"},{"Id":395945,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"16714089901"},{"Id":395946,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"16714089902"},{"Id":395947,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100310","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","NDC":"16714093601"},{"Id":395948,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100320","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","NDC":"16714093701"},{"Id":395949,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"16714094801"},{"Id":395950,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"16714094901"},{"Id":395951,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"16714095001"},{"Id":395952,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"16714095201"},{"Id":395953,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"16714095301"},{"Id":395954,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"16714095501"},{"Id":395955,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"16714095502"},{"Id":395956,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"16714095503"},{"Id":395957,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"16714096301"},{"Id":395958,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"16714096401"},{"Id":395959,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"16714097302"},{"Id":395960,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"16714097901"},{"Id":395961,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"16714097902"},{"Id":395962,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"16714098001"},{"Id":395963,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"16714098002"},{"Id":395964,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"16714098003"},{"Id":395965,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"16714098501"},{"Id":395966,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"16714098502"},{"Id":395967,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"16714098601"},{"Id":395968,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"16714098602"},{"Id":395969,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"16714098603"},{"Id":395970,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"16714098604"},{"Id":395971,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103720","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.5%","NDC":"16714098701"},{"Id":395972,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"16714098801"},{"Id":395973,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"16714098901"},{"Id":395974,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"16714099001"},{"Id":395975,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"16714099101"},{"Id":395976,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"16714099601"},{"Id":395977,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"16714099602"},{"Id":395978,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"16729000116"},{"Id":395979,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"16729000201"},{"Id":395980,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"16729000216"},{"Id":395981,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"16729000301"},{"Id":395982,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"16729000316"},{"Id":395983,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"16729000415"},{"Id":395984,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"16729000417"},{"Id":395985,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"16729000515"},{"Id":395986,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"16729000517"},{"Id":395987,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"16729000617"},{"Id":395988,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"16729000715"},{"Id":395989,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"16729000816"},{"Id":395990,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"16729000916"},{"Id":395991,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"16729001017"},{"Id":395992,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"16729001901"},{"Id":395993,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"16729001916"},{"Id":395994,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"16729002301"},{"Id":395995,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"16729002310"},{"Id":395996,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"16729003410"},{"Id":395997,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"16729003415"},{"Id":395998,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"16729003510"},{"Id":395999,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"16729003515"},{"Id":396000,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"16729003516"},{"Id":396001,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"16729004101"},{"Id":396002,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"16729004201"},{"Id":396003,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"16729004301"},{"Id":396004,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"16729004517"},{"Id":396005,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"16729004615"},{"Id":396006,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"16729004853"},{"Id":396007,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"16729004854"},{"Id":396008,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"16729004953"},{"Id":396009,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"16729004954"},{"Id":396010,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"16729005053"},{"Id":396011,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"16729005054"},{"Id":396012,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"16729005153"},{"Id":396013,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"16729007212"},{"Id":396014,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"16729007329"},{"Id":396015,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"16729007801"},{"Id":396016,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"16729007901"},{"Id":396017,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"16729007917"},{"Id":396018,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"16729008101"},{"Id":396019,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"16729008110"},{"Id":396020,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"16729009001"},{"Id":396021,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"16729009010"},{"Id":396022,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"16729009015"},{"Id":396023,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"16729009016"},{"Id":396024,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"16729009401"},{"Id":396025,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"16729009416"},{"Id":396026,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"16729011910"},{"Id":396027,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"16729011915"},{"Id":396028,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"16729011917"},{"Id":396029,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"16729012953"},{"Id":396030,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"16729012954"},{"Id":396031,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"16729013053"},{"Id":396032,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"16729013054"},{"Id":396033,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16729013401"},{"Id":396034,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"16729013416"},{"Id":396035,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"16729013501"},{"Id":396036,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"16729013516"},{"Id":396037,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"16729013600"},{"Id":396038,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"16729013616"},{"Id":396039,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"16729013700"},{"Id":396040,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"16729013716"},{"Id":396041,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"16729013800"},{"Id":396042,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"16729013816"},{"Id":396043,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"16729015615"},{"Id":396044,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"16729015617"},{"Id":396045,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"16729018201"},{"Id":396046,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"16729018217"},{"Id":396047,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"16729018301"},{"Id":396048,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"16729018317"},{"Id":396049,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"16729018401"},{"Id":396050,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"16729018929"},{"Id":396051,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"16729019417"},{"Id":396052,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"16729021101"},{"Id":396053,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"16729021117"},{"Id":396054,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"16729021301"},{"Id":396055,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"16729021317"},{"Id":396056,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"16729022501"},{"Id":396057,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"16729022516"},{"Id":396058,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"16729022517"},{"Id":396059,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"16729022601"},{"Id":396060,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"16729022616"},{"Id":396061,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"16729022701"},{"Id":396062,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"16729022716"},{"Id":396063,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"16729026129"},{"Id":396064,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100320","GenericName":"PRASUGREL HCL TAB 5 MG (BASE EQUIV)","NDC":"16729027210"},{"Id":396065,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100330","GenericName":"PRASUGREL HCL TAB 10 MG (BASE EQUIV)","NDC":"16729027310"},{"Id":396066,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 50MG/2ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102063","GenericName":"METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML)","NDC":"16729027730"},{"Id":396067,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM/40ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102075","GenericName":"METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML)","NDC":"16729027735"},{"Id":396068,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"16729028415"},{"Id":396069,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"16729028417"},{"Id":396070,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"16729028517"},{"Id":396071,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"16729028715"},{"Id":396072,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"16729028717"},{"Id":396073,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"16729029212"},{"Id":396074,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"16729029310"},{"Id":396075,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"16729029315"},{"Id":396076,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"16729029410"},{"Id":396077,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"16729029415"},{"Id":396078,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"16729030301"},{"Id":396079,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"16729030316"},{"Id":396080,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"16729030401"},{"Id":396081,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"16729030416"},{"Id":396082,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"16729030501"},{"Id":396083,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"16729030516"},{"Id":396084,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"16729031701"},{"Id":396085,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"16729031716"},{"Id":396086,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"16729031801"},{"Id":396087,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"16729031816"},{"Id":396088,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"16729031901"},{"Id":396089,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"16729032010"},{"Id":396090,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"16729032015"},{"Id":396091,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"16729032110"},{"Id":396092,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"16729032115"},{"Id":396093,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"16729032117"},{"Id":396094,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"16729032210"},{"Id":396095,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"16729032215"},{"Id":396096,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"16729032217"},{"Id":396097,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"16729033101"},{"Id":396098,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"16729034210"},{"Id":396099,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"16729036610"},{"Id":396100,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"16729036615"},{"Id":396101,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"16729036710"},{"Id":396102,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"16729036715"},{"Id":396103,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"16729036810"},{"Id":396104,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"16729036815"},{"Id":396105,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"16729041401"},{"Id":396106,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"16729041417"},{"Id":396107,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"16729041501"},{"Id":396108,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"16729041517"},{"Id":396109,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"16729041604"},{"Id":396110,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"16729041712"},{"Id":396111,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"16729042101"},{"Id":396112,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"16729042110"},{"Id":396113,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"16729042112"},{"Id":396114,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"16729042201"},{"Id":396115,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"16729042210"},{"Id":396116,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"16729042212"},{"Id":396117,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"16729043310"},{"Id":396118,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"16729044010"},{"Id":396119,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"16729044015"},{"Id":396120,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"16729044110"},{"Id":396121,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"16729044115"},{"Id":396122,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"16729044210"},{"Id":396123,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"16729044215"},{"Id":396124,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"16729044715"},{"Id":396125,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"16729044717"},{"Id":396126,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"16729044815"},{"Id":396127,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"16729044817"},{"Id":396128,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"16729044915"},{"Id":396129,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"16729044917"},{"Id":396130,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"16729045015"},{"Id":396131,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"16729045017"},{"Id":396132,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"16729045115"},{"Id":396133,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"16729045117"},{"Id":396134,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"16729045215"},{"Id":396135,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"16729045217"},{"Id":396136,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"16729045315"},{"Id":396137,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"16729045317"},{"Id":396138,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"16729045415"},{"Id":396139,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"16729045417"},{"Id":396140,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"16729045515"},{"Id":396141,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"16729045517"},{"Id":396142,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"16729045615"},{"Id":396143,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"16729045617"},{"Id":396144,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"16729045715"},{"Id":396145,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"16729045717"},{"Id":396146,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"16729045815"},{"Id":396147,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"16729046785"},{"Id":396148,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"16729047801"},{"Id":396149,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"16729047901"},{"Id":396150,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"16729048001"},{"Id":396151,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"16729048501"},{"Id":396152,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"16729048516"},{"Id":396153,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"16729048601"},{"Id":396154,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"16729049012"},{"Id":396155,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"16729049212"},{"Id":396156,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"16729050008"},{"Id":396157,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"16729050030"},{"Id":396158,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"16729050143"},{"Id":396159,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"16729050164"},{"Id":396160,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"16729050203"},{"Id":396161,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"16729050243"},{"Id":396162,"FormularyType":"OHP","DrugName":"FLUOROURACIL CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030003730","GenericName":"FLUOROURACIL CREAM 5%","NDC":"16729054235"},{"Id":396163,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"16729054910"},{"Id":396164,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"16729055010"},{"Id":396165,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"16729069209"},{"Id":396166,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"16729069309"},{"Id":396167,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"16729069409"},{"Id":396168,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"16729069506"},{"Id":396169,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"16729069606"},{"Id":396170,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"16729069706"},{"Id":396171,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"16784011133"},{"Id":396172,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"16784011143"},{"Id":396173,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"16784011163"},{"Id":396174,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"16784011372"},{"Id":396175,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"16784011392"},{"Id":396176,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"16784011393"},{"Id":396177,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"16784011612"},{"Id":396178,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"16784011613"},{"Id":396179,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"16784011622"},{"Id":396180,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"16784011623"},{"Id":396181,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"16784011631"},{"Id":396182,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011712"},{"Id":396183,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011713"},{"Id":396184,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011721"},{"Id":396185,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011722"},{"Id":396186,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011723"},{"Id":396187,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011731"},{"Id":396188,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011733"},{"Id":396189,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011751"},{"Id":396190,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011753"},{"Id":396191,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"16784011761"},{"Id":396192,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"16784011802"},{"Id":396193,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"16784011822"},{"Id":396194,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"16784011843"},{"Id":396195,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"16784011851"},{"Id":396196,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"16784011853"},{"Id":396197,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"16784011901"},{"Id":396198,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"16784011903"},{"Id":396199,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"16784011911"},{"Id":396200,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"16784011913"},{"Id":396201,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"16784012033"},{"Id":396202,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"16784012043"},{"Id":396203,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"16784012311"},{"Id":396204,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"16784012313"},{"Id":396205,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"16784012331"},{"Id":396206,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"16784012332"},{"Id":396207,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"16784012333"},{"Id":396208,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"16784012361"},{"Id":396209,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"16784012363"},{"Id":396210,"FormularyType":"OHP","DrugName":"SILIGENTLE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784030551"},{"Id":396211,"FormularyType":"OHP","DrugName":"SILIGENTLE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784030552"},{"Id":396212,"FormularyType":"OHP","DrugName":"SILIGENTLE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784030553"},{"Id":396213,"FormularyType":"OHP","DrugName":"SILIGENTLE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784030581"},{"Id":396214,"FormularyType":"OHP","DrugName":"SILIGENTLE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784030582"},{"Id":396215,"FormularyType":"OHP","DrugName":"SILIGENTLE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784030583"},{"Id":396216,"FormularyType":"OHP","DrugName":"SURGICAL SPN PAD 2\" X 2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"16784032223"},{"Id":396217,"FormularyType":"OHP","DrugName":"WE CARE ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"16784047191"},{"Id":396218,"FormularyType":"OHP","DrugName":"WE CARE ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"16784047193"},{"Id":396219,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"16784069402"},{"Id":396220,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"16784069403"},{"Id":396221,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"16784069452"},{"Id":396222,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"16784069453"},{"Id":396223,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"16784069462"},{"Id":396224,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"16784069463"},{"Id":396225,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784069472"},{"Id":396226,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784069473"},{"Id":396227,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"16784069482"},{"Id":396228,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"16784069483"},{"Id":396229,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"16784069492"},{"Id":396230,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"16784069493"},{"Id":396231,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"16784069502"},{"Id":396232,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"16784069511"},{"Id":396233,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"16784069512"},{"Id":396234,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"16784069513"},{"Id":396235,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"16784069521"},{"Id":396236,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"16784069522"},{"Id":396237,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"16784069523"},{"Id":396238,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"16784069531"},{"Id":396239,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"16784069532"},{"Id":396240,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"16784069533"},{"Id":396241,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"16784069541"},{"Id":396242,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"16784069542"},{"Id":396243,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"16784069543"},{"Id":396244,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"16784069551"},{"Id":396245,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"16784069552"},{"Id":396246,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"16784069553"},{"Id":396247,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"16784069561"},{"Id":396248,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"16784069562"},{"Id":396249,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"16784069563"},{"Id":396250,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784069571"},{"Id":396251,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784069572"},{"Id":396252,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784069573"},{"Id":396253,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"16784069581"},{"Id":396254,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"16784069582"},{"Id":396255,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"16784069583"},{"Id":396256,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"16784069591"},{"Id":396257,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"16784069592"},{"Id":396258,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"16784069593"},{"Id":396259,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"16784069603"},{"Id":396260,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"16784069613"},{"Id":396261,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"16784069643"},{"Id":396262,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206330","GenericName":"NEEDLE (DISP) 20 X 1-1/2\"","NDC":"16784069653"},{"Id":396263,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"16784069663"},{"Id":396264,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"16784069673"},{"Id":396265,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"16784069683"},{"Id":396266,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"16784069693"},{"Id":396267,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"16784069703"},{"Id":396268,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"16784069713"},{"Id":396269,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"16784069723"},{"Id":396270,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"16784069733"},{"Id":396271,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266305","GenericName":"NEEDLE (DISP) 26 X 1/2\"","NDC":"16784069743"},{"Id":396272,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276330","GenericName":"NEEDLE (DISP) 27 X 1-1/2\"","NDC":"16784069753"},{"Id":396273,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"16784069763"},{"Id":396274,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER SLI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"16784069873"},{"Id":396275,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"16784069883"},{"Id":396276,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"16784069893"},{"Id":396277,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"16784069902"},{"Id":396278,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"16784069903"},{"Id":396279,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"16784069913"},{"Id":396280,"FormularyType":"OHP","DrugName":"30ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006330","GenericName":"SYRINGE (DISPOSABLE) 30 ML","NDC":"16784069923"},{"Id":396281,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"16784069933"},{"Id":396282,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"16784069943"},{"Id":396283,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"16784069953"},{"Id":396284,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"16784069963"},{"Id":396285,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"16784069973"},{"Id":396286,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"16784069983"},{"Id":396287,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22G X 1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"16784069993"},{"Id":396288,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"16784070003"},{"Id":396289,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"16784070013"},{"Id":396290,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"16784070023"},{"Id":396291,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"16784070033"},{"Id":396292,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056320","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1\"","NDC":"16784070043"},{"Id":396293,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056325","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1-1/2\"","NDC":"16784070053"},{"Id":396294,"FormularyType":"OHP","DrugName":"5ML SYRINGES MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056330","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1\"","NDC":"16784070063"},{"Id":396295,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056340","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 21 X 1-1/2\"","NDC":"16784070073"},{"Id":396296,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056360","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 22 X 1-1/2\"","NDC":"16784070093"},{"Id":396297,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106320","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 20 X 1\"","NDC":"16784070103"},{"Id":396298,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106325","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 20 X 1-1/2\"","NDC":"16784070113"},{"Id":396299,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106330","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1\"","NDC":"16784070123"},{"Id":396300,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106350","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 22 X 1\"","NDC":"16784070143"},{"Id":396301,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106360","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 22 X 1-1/2\"","NDC":"16784070153"},{"Id":396302,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"16784070242"},{"Id":396303,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"16784070243"},{"Id":396304,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"16784070252"},{"Id":396305,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"16784070253"},{"Id":396306,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"16784070262"},{"Id":396307,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"16784070263"},{"Id":396308,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"16784070272"},{"Id":396309,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"16784070273"},{"Id":396310,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"16784070282"},{"Id":396311,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"16784070283"},{"Id":396312,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"16784089012"},{"Id":396313,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"16784089013"},{"Id":396314,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784089042"},{"Id":396315,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"16784089043"},{"Id":396316,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"16784089253"},{"Id":396317,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"16784089283"},{"Id":396318,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"16784089683"},{"Id":396319,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"16784089733"},{"Id":396320,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"16784096562"},{"Id":396321,"FormularyType":"OHP","DrugName":"SECURESAFE MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"16784096563"},{"Id":396322,"FormularyType":"OHP","DrugName":"VITATHELY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"17139080030"},{"Id":396323,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"17271070002"},{"Id":396324,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"17271070003"},{"Id":396325,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"17271070005"},{"Id":396326,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"17271070006"},{"Id":396327,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"17271070007"},{"Id":396328,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"17271070102"},{"Id":396329,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"17271070103"},{"Id":396330,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"17271070105"},{"Id":396331,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"17271070106"},{"Id":396332,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"17271070107"},{"Id":396333,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 3%","DosageForm":"SOLN - Solution","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002030","GenericName":"SODIUM CHLORIDE IV SOLN 3%","NDC":"17271070306"},{"Id":396334,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"17271072002"},{"Id":396335,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"17271072003"},{"Id":396336,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"17271072005"},{"Id":396337,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"17271072006"},{"Id":396338,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"17271072007"},{"Id":396339,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"17271072105"},{"Id":396340,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"17271072106"},{"Id":396341,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"17271072107"},{"Id":396342,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"17271075007"},{"Id":396343,"FormularyType":"OHP","DrugName":"REALITY ULTR MIS THIN","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"19283023271"},{"Id":396344,"FormularyType":"OHP","DrugName":"CHILD ALLRGY SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"19283028152"},{"Id":396345,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"19283031179"},{"Id":396346,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"19283048956"},{"Id":396347,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"19283048959"},{"Id":396348,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"19283059475"},{"Id":396349,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"19283065818"},{"Id":396350,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"19283065820"},{"Id":396351,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"19283066275"},{"Id":396352,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"19283066276"},{"Id":396353,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"19283073833"},{"Id":396354,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"19283074045"},{"Id":396355,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"19283074047"},{"Id":396356,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"19283074048"},{"Id":396357,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"19283074049"},{"Id":396358,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"19283074050"},{"Id":396359,"FormularyType":"OHP","DrugName":"ALLERGY 24HR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"19283080207"},{"Id":396360,"FormularyType":"OHP","DrugName":"REALITY ULTR MIS TEXTURED","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"19283092332"},{"Id":396361,"FormularyType":"OHP","DrugName":"FLULAVAL INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"19515090441"},{"Id":396362,"FormularyType":"OHP","DrugName":"FLULAVAL INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"19515090452"},{"Id":396363,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"20555000300"},{"Id":396364,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"20555000301"},{"Id":396365,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"20555000500"},{"Id":396366,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"20555000600"},{"Id":396367,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"20555001600"},{"Id":396368,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"20555001700"},{"Id":396369,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000318","GenericName":"FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON)","NDC":"20555001900"},{"Id":396370,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"20555002101"},{"Id":396371,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640320","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"20555002500"},{"Id":396372,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"20555003200"},{"Id":396373,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"20555003300"},{"Id":396374,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"20555003600"},{"Id":396375,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"20555003601"},{"Id":396376,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"20555003900"},{"Id":396377,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"20555003901"},{"Id":396378,"FormularyType":"OHP","DrugName":"TITRALAC CHW 420MG","DosageForm":"CHEW - Tablet Chewable","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000505","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 420 MG","NDC":"21200076591"},{"Id":396379,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"21292000022"},{"Id":396380,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUCOSE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"21292000431"},{"Id":396381,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUCOSE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"21292000432"},{"Id":396382,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUC ORG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"21292000434"},{"Id":396383,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLU RASP","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"21292000435"},{"Id":396384,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"21292000446"},{"Id":396385,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 33G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"21292000448"},{"Id":396386,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"21292000495"},{"Id":396387,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"21292000496"},{"Id":396388,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"21292000497"},{"Id":396389,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"21292000498"},{"Id":396390,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"21292000499"},{"Id":396391,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"21292000500"},{"Id":396392,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"21292000501"},{"Id":396393,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"21292000502"},{"Id":396394,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"21292000503"},{"Id":396395,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"21292000504"},{"Id":396396,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"21292000505"},{"Id":396397,"FormularyType":"OHP","DrugName":"TRUE METRIX SOL LEVEL 1","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100930","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID - LOW***","NDC":"21292000623"},{"Id":396398,"FormularyType":"OHP","DrugName":"TRUE METRIX SOL LEVEL 2","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100920","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID - NORMAL***","NDC":"21292000624"},{"Id":396399,"FormularyType":"OHP","DrugName":"TRUE METRIX SOL LEVEL 3","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100910","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID - HIGH***","NDC":"21292000625"},{"Id":396400,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"21292000628"},{"Id":396401,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"21292001052"},{"Id":396402,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"21292001053"},{"Id":396403,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"21292001076"},{"Id":396404,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"21292001077"},{"Id":396405,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"21292001078"},{"Id":396406,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"21292001079"},{"Id":396407,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"21292001080"},{"Id":396408,"FormularyType":"OHP","DrugName":"CEFOTAXIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300075102105","GenericName":"CEFOTAXIME SODIUM FOR INJ 1 GM","NDC":"21586001101"},{"Id":396409,"FormularyType":"OHP","DrugName":"CEFOTAXIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300075102105","GenericName":"CEFOTAXIME SODIUM FOR INJ 1 GM","NDC":"21586001102"},{"Id":396410,"FormularyType":"OHP","DrugName":"CEFOTAXIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300075102110","GenericName":"CEFOTAXIME SODIUM FOR INJ 2 GM","NDC":"21586001201"},{"Id":396411,"FormularyType":"OHP","DrugName":"CEFOTAXIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300075102110","GenericName":"CEFOTAXIME SODIUM FOR INJ 2 GM","NDC":"21586001202"},{"Id":396412,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"21922000101"},{"Id":396413,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"21922000201"},{"Id":396414,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"21922000221"},{"Id":396415,"FormularyType":"OHP","DrugName":"FLUOCINOLONE SOL 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550055102005","GenericName":"FLUOCINOLONE ACETONIDE SOLN 0.01%","NDC":"21922000301"},{"Id":396416,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"21922001105"},{"Id":396417,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"21922001107"},{"Id":396418,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"21922001109"},{"Id":396419,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"21922001604"},{"Id":396420,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"21922001605"},{"Id":396421,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"21922001606"},{"Id":396422,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"21922001607"},{"Id":396423,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"21922001704"},{"Id":396424,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"21922001705"},{"Id":396425,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"21922001706"},{"Id":396426,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"21922001707"},{"Id":396427,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"21922001902"},{"Id":396428,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL PUMP 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004040","GenericName":"TESTOSTERONE TD GEL 12.5 MG/ACT (1%)","NDC":"21922001947"},{"Id":396429,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(25MG)","DosageForm":"GEL - Gel","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004025","GenericName":"TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","NDC":"21922001952"},{"Id":396430,"FormularyType":"OHP","DrugName":"PERMETHRIN CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035003720","GenericName":"PERMETHRIN CREAM 5%","NDC":"21922002107"},{"Id":396431,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"21922002504"},{"Id":396432,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"21922002505"},{"Id":396433,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"21922002507"},{"Id":396434,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"21922002705"},{"Id":396435,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"21922002707"},{"Id":396436,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"21922003020"},{"Id":396437,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"21922003104"},{"Id":396438,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"21922003105"},{"Id":396439,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"21922003107"},{"Id":396440,"FormularyType":"OHP","DrugName":"CLINDAMYCIN LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104105","GenericName":"CLINDAMYCIN PHOSPHATE LOTION 1%","NDC":"21922003601"},{"Id":396441,"FormularyType":"OHP","DrugName":"AZELAIC ACID GEL 15%","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060010004020","GenericName":"AZELAIC ACID GEL 15%","NDC":"21922003814"},{"Id":396442,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"21922003923"},{"Id":396443,"FormularyType":"OHP","DrugName":"FLUOROURACIL SOL 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030002050","GenericName":"FLUOROURACIL SOLN 5%","NDC":"21922004112"},{"Id":396444,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"21922004409"},{"Id":396445,"FormularyType":"OHP","DrugName":"MESALAMINE ENE 4GM","DosageForm":"ENEM - Enema","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005105","GenericName":"MESALAMINE ENEMA 4 GM","NDC":"21922004547"},{"Id":396446,"FormularyType":"OHP","DrugName":"MESALAMINE ENE 4GM","DosageForm":"ENEM - Enema","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005105","GenericName":"MESALAMINE ENEMA 4 GM","NDC":"21922004549"},{"Id":396447,"FormularyType":"OHP","DrugName":"FLUOROURACIL CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030003730","GenericName":"FLUOROURACIL CREAM 5%","NDC":"21922004917"},{"Id":396448,"FormularyType":"OHP","DrugName":"ADAPAL/BEN P GEL 0.1-2.5%","DosageForm":"GEL - Gel","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90059902034020","GenericName":"ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5%","NDC":"21922005250"},{"Id":396449,"FormularyType":"OHP","DrugName":"CICLOPIROX SOL 8%","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030002020","GenericName":"CICLOPIROX SOLUTION 8%","NDC":"21922005351"},{"Id":396450,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"21922006122"},{"Id":396451,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"21922006127"},{"Id":396452,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"21922006204"},{"Id":396453,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"21922006205"},{"Id":396454,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"21922006215"},{"Id":396455,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"21922006230"},{"Id":396456,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"21922006304"},{"Id":396457,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"21922006305"},{"Id":396458,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"21922006315"},{"Id":396459,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"21922006330"},{"Id":396460,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040004010","GenericName":"METRONIDAZOLE GEL 0.75%","NDC":"21922007006"},{"Id":396461,"FormularyType":"OHP","DrugName":"MOMETASONE SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082102010","GenericName":"MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","NDC":"21922007201"},{"Id":396462,"FormularyType":"OHP","DrugName":"MOMETASONE SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082102010","GenericName":"MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","NDC":"21922007221"},{"Id":396463,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"21922007304"},{"Id":396464,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"21922007325"},{"Id":396465,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"21922007504"},{"Id":396466,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"21922007505"},{"Id":396467,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"21922007507"},{"Id":396468,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"21922007605"},{"Id":396469,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"21922007906"},{"Id":396470,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"21922007925"},{"Id":396471,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"21922008506"},{"Id":396472,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"21922009104"},{"Id":396473,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"21922009105"},{"Id":396474,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"21922009305"},{"Id":396475,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"21922009404"},{"Id":396476,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"21922009405"},{"Id":396477,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"21922009506"},{"Id":396478,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"21922009705"},{"Id":396479,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"21922009805"},{"Id":396480,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"21922010105"},{"Id":396481,"FormularyType":"OHP","DrugName":"TROJAN MAGN MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600064203"},{"Id":396482,"FormularyType":"OHP","DrugName":"TROJAN MIS ENZ","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010206200","GenericName":"CONDOMS LATEX NON-LUBRICATED","NDC":"22600092050"},{"Id":396483,"FormularyType":"OHP","DrugName":"TROJAN ULTRA MIS THIN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600092620"},{"Id":396484,"FormularyType":"OHP","DrugName":"TROJAN ULTRA MIS THIN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600092720"},{"Id":396485,"FormularyType":"OHP","DrugName":"TROJAN-ENZ MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600093050"},{"Id":396486,"FormularyType":"OHP","DrugName":"TROJAN-ENZ MIS W/SPERMI","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600093150"},{"Id":396487,"FormularyType":"OHP","DrugName":"TROJAN ULTRA MIS RIBBED","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600094050"},{"Id":396488,"FormularyType":"OHP","DrugName":"TROJAN MIS BARESKIN","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600099853"},{"Id":396489,"FormularyType":"OHP","DrugName":"TROJAN MIS BARESKIN","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"22600099965"},{"Id":396490,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"23155000101"},{"Id":396491,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"23155000110"},{"Id":396492,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"23155000201"},{"Id":396493,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"23155000210"},{"Id":396494,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"23155000301"},{"Id":396495,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"23155000310"},{"Id":396496,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"23155000801"},{"Id":396497,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"23155000810"},{"Id":396498,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"23155000901"},{"Id":396499,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"23155000910"},{"Id":396500,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"23155001701"},{"Id":396501,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100305","GenericName":"VERAPAMIL HCL TAB 80 MG","NDC":"23155002601"},{"Id":396502,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"23155004303"},{"Id":396503,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"23155004403"},{"Id":396504,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"23155004801"},{"Id":396505,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"23155004901"},{"Id":396506,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"23155005001"},{"Id":396507,"FormularyType":"OHP","DrugName":"NYSTATIN TAB 500000","DosageForm":"TABS - Tablet","Strength":"500000","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000060000305","GenericName":"NYSTATIN TAB 500000 UNIT","NDC":"23155005101"},{"Id":396508,"FormularyType":"OHP","DrugName":"NARATRIPTAN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406050100310","GenericName":"NARATRIPTAN HCL TAB 1 MG (BASE EQUIV)","NDC":"23155005419"},{"Id":396509,"FormularyType":"OHP","DrugName":"NARATRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406050100320","GenericName":"NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV)","NDC":"23155005519"},{"Id":396510,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000305","GenericName":"GLYBURIDE TAB 1.25 MG","NDC":"23155005601"},{"Id":396511,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"23155005701"},{"Id":396512,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"23155005801"},{"Id":396513,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"23155005810"},{"Id":396514,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100303","GenericName":"VERAPAMIL HCL TAB 40 MG","NDC":"23155005901"},{"Id":396515,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"23155007001"},{"Id":396516,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"23155007101"},{"Id":396517,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"23155009201"},{"Id":396518,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"23155009301"},{"Id":396519,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"23155009401"},{"Id":396520,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"23155009501"},{"Id":396521,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-250M","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350320","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG","NDC":"23155011501"},{"Id":396522,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-500M","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350325","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG","NDC":"23155011601"},{"Id":396523,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350340","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 5-500 MG","NDC":"23155011701"},{"Id":396524,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000305","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 50 MG","NDC":"23155013301"},{"Id":396525,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"23155013505"},{"Id":396526,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"23155013525"},{"Id":396527,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000310","GenericName":"ACARBOSE TAB 25 MG","NDC":"23155014701"},{"Id":396528,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000320","GenericName":"ACARBOSE TAB 50 MG","NDC":"23155014801"},{"Id":396529,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000340","GenericName":"ACARBOSE TAB 100 MG","NDC":"23155014901"},{"Id":396530,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"23155019331"},{"Id":396531,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"23155019341"},{"Id":396532,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000105","GenericName":"NIFEDIPINE CAP 10 MG","NDC":"23155019401"},{"Id":396533,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000110","GenericName":"NIFEDIPINE CAP 20 MG","NDC":"23155019501"},{"Id":396534,"FormularyType":"OHP","DrugName":"CIDOFOVIR INJ 75MG/ML","DosageForm":"SOLN - Solution","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200010002020","GenericName":"CIDOFOVIR IV INJ 75 MG/ML","NDC":"23155021631"},{"Id":396535,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"23155022701"},{"Id":396536,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"23155022705"},{"Id":396537,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"23155022801"},{"Id":396538,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"23155022805"},{"Id":396539,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"23155022901"},{"Id":396540,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"23155022905"},{"Id":396541,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 1.25-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400310","GenericName":"GLYBURIDE-METFORMIN TAB 1.25-250 MG","NDC":"23155023301"},{"Id":396542,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400320","GenericName":"GLYBURIDE-METFORMIN TAB 2.5-500 MG","NDC":"23155023401"},{"Id":396543,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400330","GenericName":"GLYBURIDE-METFORMIN TAB 5-500 MG","NDC":"23155023501"},{"Id":396544,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"23155024031"},{"Id":396545,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"23155024041"},{"Id":396546,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"23155026331"},{"Id":396547,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"23155026431"},{"Id":396548,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"23155026441"},{"Id":396549,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"23155028701"},{"Id":396550,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"23155028801"},{"Id":396551,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"23155029031"},{"Id":396552,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"23155029032"},{"Id":396553,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"23155029041"},{"Id":396554,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"23155029042"},{"Id":396555,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"23155036201"},{"Id":396556,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"23155036205"},{"Id":396557,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"23155047331"},{"Id":396558,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"23155047332"},{"Id":396559,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"23155047333"},{"Id":396560,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"23155047341"},{"Id":396561,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"23155047342"},{"Id":396562,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"23155047344"},{"Id":396563,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100310","GenericName":"VERAPAMIL HCL TAB 120 MG","NDC":"23155048601"},{"Id":396564,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100310","GenericName":"DESMOPRESSIN ACETATE TAB 0.1 MG","NDC":"23155048901"},{"Id":396565,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100320","GenericName":"DESMOPRESSIN ACETATE TAB 0.2 MG","NDC":"23155049001"},{"Id":396566,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"23155050001"},{"Id":396567,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"23155050005"},{"Id":396568,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"23155050010"},{"Id":396569,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"23155050101"},{"Id":396570,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"23155050105"},{"Id":396571,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"23155050110"},{"Id":396572,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"23155050201"},{"Id":396573,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"23155050205"},{"Id":396574,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"23155050210"},{"Id":396575,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"23155053005"},{"Id":396576,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"23155053006"},{"Id":396577,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"23155053102"},{"Id":396578,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010000105","GenericName":"ETHOSUXIMIDE CAP 250 MG","NDC":"23155053201"},{"Id":396579,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"23155060132"},{"Id":396580,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"23155060142"},{"Id":396581,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"23155060351"},{"Id":396582,"FormularyType":"OHP","DrugName":"CALC ACETATE TAB 667MG","DosageForm":"TABS - Tablet","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100320","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG","NDC":"23155062102"},{"Id":396583,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"23155065101"},{"Id":396584,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"23155065105"},{"Id":396585,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"23155065201"},{"Id":396586,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"23155065205"},{"Id":396587,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"23155066201"},{"Id":396588,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"23155066203"},{"Id":396589,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.5MCG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000110","GenericName":"CALCITRIOL CAP 0.5 MCG","NDC":"23155066301"},{"Id":396590,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 5000/5ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102030","GenericName":"OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML)","NDC":"23155068631"},{"Id":396591,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"23155068831"},{"Id":396592,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"23155068841"},{"Id":396593,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"23155069301"},{"Id":396594,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"23155069310"},{"Id":396595,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"23155069405"},{"Id":396596,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"23155070401"},{"Id":396597,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"23155070410"},{"Id":396598,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"23155070501"},{"Id":396599,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"23155070510"},{"Id":396600,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"23155072301"},{"Id":396601,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"23155072305"},{"Id":396602,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"23155072401"},{"Id":396603,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"23155072405"},{"Id":396604,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"23155072501"},{"Id":396605,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"23155072505"},{"Id":396606,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"23155073501"},{"Id":396607,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"23155073510"},{"Id":396608,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"23155073601"},{"Id":396609,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"23155073610"},{"Id":396610,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"23155073701"},{"Id":396611,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"23155073710"},{"Id":396612,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"23155073801"},{"Id":396613,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"23155073810"},{"Id":396614,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"23155074101"},{"Id":396615,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"23155074201"},{"Id":396616,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"23155074901"},{"Id":396617,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"23155074905"},{"Id":396618,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"23155075001"},{"Id":396619,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"23155075005"},{"Id":396620,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"23155075101"},{"Id":396621,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"23155075105"},{"Id":396622,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"23155075201"},{"Id":396623,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"23155075205"},{"Id":396624,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"23155076401"},{"Id":396625,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"23155076410"},{"Id":396626,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"23155076701"},{"Id":396627,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"23155077201"},{"Id":396628,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"23155077210"},{"Id":396629,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"23155077301"},{"Id":396630,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"23155077310"},{"Id":396631,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"23155078531"},{"Id":396632,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"23155078541"},{"Id":396633,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"23155078631"},{"Id":396634,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"23155078641"},{"Id":396635,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"23155078701"},{"Id":396636,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"23155081001"},{"Id":396637,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"23155081005"},{"Id":396638,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"23155081010"},{"Id":396639,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"23155082373"},{"Id":396640,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"23155083001"},{"Id":396641,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"23155083005"},{"Id":396642,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"23155083201"},{"Id":396643,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"23155083210"},{"Id":396644,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"23155083301"},{"Id":396645,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"23155083310"},{"Id":396646,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"23155083401"},{"Id":396647,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"23155083410"},{"Id":396648,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"23155083501"},{"Id":396649,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"23155083601"},{"Id":396650,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"23155083605"},{"Id":396651,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"23155083711"},{"Id":396652,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"23155083730"},{"Id":396653,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 50MG MOD","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300130","GenericName":"CYCLOSPORINE MODIFIED CAP 50 MG","NDC":"23155083811"},{"Id":396654,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 50MG MOD","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300130","GenericName":"CYCLOSPORINE MODIFIED CAP 50 MG","NDC":"23155083830"},{"Id":396655,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"23155083911"},{"Id":396656,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"23155083930"},{"Id":396657,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"23155084101"},{"Id":396658,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"23155084105"},{"Id":396659,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"23155084110"},{"Id":396660,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"23155084201"},{"Id":396661,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"23155084205"},{"Id":396662,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"23155084210"},{"Id":396663,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"23155084301"},{"Id":396664,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"23155084305"},{"Id":396665,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"23155084310"},{"Id":396666,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"23155084851"},{"Id":396667,"FormularyType":"OHP","DrugName":"CHLOROQUINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000010200310","GenericName":"CHLOROQUINE PHOSPHATE TAB 500 MG","NDC":"23155085074"},{"Id":396668,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"23155085501"},{"Id":396669,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"23155085703"},{"Id":396670,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"23155085705"},{"Id":396671,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"23155085709"},{"Id":396672,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"23155085825"},{"Id":396673,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"23155085878"},{"Id":396674,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"23155085925"},{"Id":396675,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"23155085978"},{"Id":396676,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000105","GenericName":"FLUCYTOSINE CAP 250 MG","NDC":"23155086001"},{"Id":396677,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000105","GenericName":"FLUCYTOSINE CAP 250 MG","NDC":"23155086003"},{"Id":396678,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000110","GenericName":"FLUCYTOSINE CAP 500 MG","NDC":"23155086101"},{"Id":396679,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000110","GenericName":"FLUCYTOSINE CAP 500 MG","NDC":"23155086103"},{"Id":396680,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"23155086601"},{"Id":396681,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"23155086605"},{"Id":396682,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"23155086701"},{"Id":396683,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"23155086705"},{"Id":396684,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"23155086801"},{"Id":396685,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"23155086805"},{"Id":396686,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"23155087101"},{"Id":396687,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"23155087201"},{"Id":396688,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"23155087301"},{"Id":396689,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"23155087401"},{"Id":396690,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"23155087503"},{"Id":396691,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"23155087509"},{"Id":396692,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"23155087510"},{"Id":396693,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"23155087601"},{"Id":396694,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"23155087605"},{"Id":396695,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"23155087701"},{"Id":396696,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"23155087710"},{"Id":396697,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"23155087801"},{"Id":396698,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"23155087810"},{"Id":396699,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"23155087901"},{"Id":396700,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"23155087910"},{"Id":396701,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"23155088001"},{"Id":396702,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"23155088005"},{"Id":396703,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"23155088101"},{"Id":396704,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"23155088110"},{"Id":396705,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"23155088601"},{"Id":396706,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"23155088603"},{"Id":396707,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006820","GenericName":"TOPIRAMATE SPRINKLE CAP 15 MG","NDC":"23155089406"},{"Id":396708,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"23155089801"},{"Id":396709,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"23155089805"},{"Id":396710,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"23155089901"},{"Id":396711,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"23155089905"},{"Id":396712,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"23155090101"},{"Id":396713,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"23155090105"},{"Id":396714,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"23155090201"},{"Id":396715,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"23155090205"},{"Id":396716,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102105","GenericName":"NAFCILLIN SODIUM FOR INJ 1 GM","NDC":"23155090631"},{"Id":396717,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102105","GenericName":"NAFCILLIN SODIUM FOR INJ 1 GM","NDC":"23155090641"},{"Id":396718,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"23155090731"},{"Id":396719,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"23155090741"},{"Id":396720,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"23155091141"},{"Id":396721,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"23155091142"},{"Id":396722,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"23155091231"},{"Id":396723,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"23155091241"},{"Id":396724,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"23155091531"},{"Id":396725,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"23155091541"},{"Id":396726,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"23155091631"},{"Id":396727,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"23155091641"},{"Id":396728,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"23155091731"},{"Id":396729,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"23155091741"},{"Id":396730,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 2.5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200120","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","NDC":"23155092001"},{"Id":396731,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"23155092201"},{"Id":396732,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"23155092501"},{"Id":396733,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"23155092651"},{"Id":396734,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"23155092681"},{"Id":396735,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"23155092751"},{"Id":396736,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"23155092752"},{"Id":396737,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"23155092952"},{"Id":396738,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100310","GenericName":"BETHANECHOL CHLORIDE TAB 5 MG","NDC":"23155093401"},{"Id":396739,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"23155093501"},{"Id":396740,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"23155093601"},{"Id":396741,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100340","GenericName":"BETHANECHOL CHLORIDE TAB 50 MG","NDC":"23155093701"},{"Id":396742,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"23155093863"},{"Id":396743,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"23155093963"},{"Id":396744,"FormularyType":"OHP","DrugName":"MINI WRIGHT MIS PFM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"23323001122"},{"Id":396745,"FormularyType":"OHP","DrugName":"REESES MED SUS PINWORM","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"23513061801"},{"Id":396746,"FormularyType":"OHP","DrugName":"REESES MED SUS PINWORM","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"23513061821"},{"Id":396747,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"24201020701"},{"Id":396748,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000303","GenericName":"METHAZOLAMIDE TAB 25 MG","NDC":"24208002210"},{"Id":396749,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000305","GenericName":"METHAZOLAMIDE TAB 50 MG","NDC":"24208002310"},{"Id":396750,"FormularyType":"OHP","DrugName":"INSTA-GLUCOS GEL 77.4%","DosageForm":"GEL - Gel","Strength":"77.4","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004070","GenericName":"GLUCOSE GEL 77.4%","NDC":"24208002401"},{"Id":396751,"FormularyType":"OHP","DrugName":"INSTA-GLUCOS GEL 77.4%","DosageForm":"GEL - Gel","Strength":"77.4","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004070","GenericName":"GLUCOSE GEL 77.4%","NDC":"24208002402"},{"Id":396752,"FormularyType":"OHP","DrugName":"TOBRAMYCIN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101070002005","GenericName":"TOBRAMYCIN OPHTH SOLN 0.3%","NDC":"24208029005"},{"Id":396753,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"24208029505"},{"Id":396754,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"24208029510"},{"Id":396755,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"24208029525"},{"Id":396756,"FormularyType":"OHP","DrugName":"POLYMYXIN B/ SOL TRIMETHP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86109902602020","GenericName":"POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1%","NDC":"24208031510"},{"Id":396757,"FormularyType":"OHP","DrugName":"SULF/PRED NA SOL OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902722015","GenericName":"SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SOLN 10-0.23(0.25)%","NDC":"24208031705"},{"Id":396758,"FormularyType":"OHP","DrugName":"DESMOPRESSIN SPR 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010122010","GenericName":"DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED)","NDC":"24208034205"},{"Id":396759,"FormularyType":"OHP","DrugName":"FLUNISOLIDE SPR 0.025%","DosageForm":"SOLN - Solution","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200030002005","GenericName":"FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%)","NDC":"24208034425"},{"Id":396760,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"24208039830"},{"Id":396761,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"24208041005"},{"Id":396762,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"24208041010"},{"Id":396763,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"24208041105"},{"Id":396764,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"24208041110"},{"Id":396765,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"24208041115"},{"Id":396766,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"24208043405"},{"Id":396767,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"24208043410"},{"Id":396768,"FormularyType":"OHP","DrugName":"DICLOFENAC SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805010102010","GenericName":"DICLOFENAC SODIUM OPHTH SOLN 0.1%","NDC":"24208045705"},{"Id":396769,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"24208046325"},{"Id":396770,"FormularyType":"OHP","DrugName":"BRINZOLAMIDE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802320001820","GenericName":"BRINZOLAMIDE OPHTH SUSP 1%","NDC":"24208046410"},{"Id":396771,"FormularyType":"OHP","DrugName":"BRINZOLAMIDE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802320001820","GenericName":"BRINZOLAMIDE OPHTH SUSP 1%","NDC":"24208046415"},{"Id":396772,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"24208048510"},{"Id":396773,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"24208048610"},{"Id":396774,"FormularyType":"OHP","DrugName":"LEVOBUNOLOL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250020102005","GenericName":"LEVOBUNOLOL HCL OPHTH SOLN 0.5%","NDC":"24208050505"},{"Id":396775,"FormularyType":"OHP","DrugName":"ZIRGAN GEL 0.15%","DosageForm":"GEL - Gel","Strength":"0.15","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86103007004020","GenericName":"GANCICLOVIR OPHTH GEL 0.15%","NDC":"24208053535"},{"Id":396776,"FormularyType":"OHP","DrugName":"BACIT/POLYMY OIN OP","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86109902104200","GenericName":"BACITRACIN-POLYMYXIN B OPHTH OINT","NDC":"24208055555"},{"Id":396777,"FormularyType":"OHP","DrugName":"GENTAMICIN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101030002005","GenericName":"GENTAMICIN SULFATE OPHTH SOLN 0.3%","NDC":"24208058060"},{"Id":396778,"FormularyType":"OHP","DrugName":"TROPICAMIDE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350050002010","GenericName":"TROPICAMIDE OPHTH SOLN 1%","NDC":"24208058564"},{"Id":396779,"FormularyType":"OHP","DrugName":"TROPICAMIDE SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350050002005","GenericName":"TROPICAMIDE OPHTH SOLN 0.5%","NDC":"24208059064"},{"Id":396780,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SOL 1% OTIC","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991003102010","GenericName":"NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%","NDC":"24208063110"},{"Id":396781,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SUS 1% OTIC","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991003101807","GenericName":"NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%","NDC":"24208063562"},{"Id":396782,"FormularyType":"OHP","DrugName":"SULFACET SOD SOL 10% OP","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86102010102010","GenericName":"SULFACETAMIDE SODIUM OPHTH SOLN 10%","NDC":"24208067004"},{"Id":396783,"FormularyType":"OHP","DrugName":"PRED SOD PHO SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050202015","GenericName":"PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1%","NDC":"24208071510"},{"Id":396784,"FormularyType":"OHP","DrugName":"DEXAMETH PHO SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300010102005","GenericName":"DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1%","NDC":"24208072002"},{"Id":396785,"FormularyType":"OHP","DrugName":"CYCLOPENTOL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350020102010","GenericName":"CYCLOPENTOLATE HCL OPHTH SOLN 1%","NDC":"24208073501"},{"Id":396786,"FormularyType":"OHP","DrugName":"CYCLOPENTOL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350020102010","GenericName":"CYCLOPENTOLATE HCL OPHTH SOLN 1%","NDC":"24208073506"},{"Id":396787,"FormularyType":"OHP","DrugName":"NEO/POLY/BAC OIN OP","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86109903104220","GenericName":"NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN","NDC":"24208078055"},{"Id":396788,"FormularyType":"OHP","DrugName":"NEO/POLY/BAC OIN /HC 1%OP","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309904104220","GenericName":"BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1%","NDC":"24208078555"},{"Id":396789,"FormularyType":"OHP","DrugName":"NEO/POLY/GRA SOL OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86109903202000","GenericName":"NEOMYCIN-POLYMY-GRAMICID OP SOL 1.75-10000-0.025MG-UNT-MG/ML","NDC":"24208079062"},{"Id":396790,"FormularyType":"OHP","DrugName":"NEO/POLY/DEX OIN 0.1% OP","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309903324210","GenericName":"NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%","NDC":"24208079535"},{"Id":396791,"FormularyType":"OHP","DrugName":"NEO/POLY/DEX SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309903321810","GenericName":"NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%","NDC":"24208083060"},{"Id":396792,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN OIN 0.5% OP","DosageForm":"OINT - Ointment","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101025004210","GenericName":"ERYTHROMYCIN OPHTH OINT 5 MG/GM","NDC":"24208091019"},{"Id":396793,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN OIN 0.5% OP","DosageForm":"OINT - Ointment","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101025004210","GenericName":"ERYTHROMYCIN OPHTH OINT 5 MG/GM","NDC":"24208091055"},{"Id":396794,"FormularyType":"OHP","DrugName":"DANZITEN TAB 71MG","DosageForm":"TABS - Tablet","Strength":"71","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860600320","GenericName":"NILOTINIB TARTRATE TAB 71 MG (BASE EQUIVALENT)","NDC":"24338015401"},{"Id":396795,"FormularyType":"OHP","DrugName":"DANZITEN TAB 95MG","DosageForm":"TABS - Tablet","Strength":"95","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860600330","GenericName":"NILOTINIB TARTRATE TAB 95 MG (BASE EQUIVALENT)","NDC":"24338015501"},{"Id":396796,"FormularyType":"OHP","DrugName":"ENU NUTRITIO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359032224"},{"Id":396797,"FormularyType":"OHP","DrugName":"ENU NUTRITIO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359032324"},{"Id":396798,"FormularyType":"OHP","DrugName":"ESSENTIAL LIQ CARE JR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359038041"},{"Id":396799,"FormularyType":"OHP","DrugName":"KETOVIE 4:1 LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050103"},{"Id":396800,"FormularyType":"OHP","DrugName":"KETOVIE 4:1 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050203"},{"Id":396801,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RESTOR10","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050302"},{"Id":396802,"FormularyType":"OHP","DrugName":"KETOVIE LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050303"},{"Id":396803,"FormularyType":"OHP","DrugName":"KETOVIE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050403"},{"Id":396804,"FormularyType":"OHP","DrugName":"KETOVIE 3:1 LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050404"},{"Id":396805,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RESTOR10","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050502"},{"Id":396806,"FormularyType":"OHP","DrugName":"KETOVIE LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359050603"},{"Id":396807,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RES/LITE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359051302"},{"Id":396808,"FormularyType":"OHP","DrugName":"GLYTACTIN 15 LIQ RTD LITE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359051403"},{"Id":396809,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RES/LITE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359051502"},{"Id":396810,"FormularyType":"OHP","DrugName":"GLYTACTIN 15 LIQ RTD LITE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359051803"},{"Id":396811,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RTD 15","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359054403"},{"Id":396812,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RTD 10","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359056403"},{"Id":396813,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RTD 10","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359057403"},{"Id":396814,"FormularyType":"OHP","DrugName":"TYLACTIN LIQ REST 10","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359057502"},{"Id":396815,"FormularyType":"OHP","DrugName":"GLYTACTIN LIQ RTD 15","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359058403"},{"Id":396816,"FormularyType":"OHP","DrugName":"TYLACTIN LIQ RTD 15","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359059203"},{"Id":396817,"FormularyType":"OHP","DrugName":"TYLACTIN RTD LIQ 15 CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359059204"},{"Id":396818,"FormularyType":"OHP","DrugName":"KETOVIE 4:1 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359060303"},{"Id":396819,"FormularyType":"OHP","DrugName":"HOMACTIN AA LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359070103"},{"Id":396820,"FormularyType":"OHP","DrugName":"VILACTIN AA LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"24359070403"},{"Id":396821,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385000926"},{"Id":396822,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385000934"},{"Id":396823,"FormularyType":"OHP","DrugName":"PINK BISMUTH TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"24385001758"},{"Id":396824,"FormularyType":"OHP","DrugName":"GNP HYDROCOR CRE 1% PLUS","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"24385002103"},{"Id":396825,"FormularyType":"OHP","DrugName":"GNP ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"24385002868"},{"Id":396826,"FormularyType":"OHP","DrugName":"GNP NASAL TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"24385005452"},{"Id":396827,"FormularyType":"OHP","DrugName":"GNP NASAL TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"24385005461"},{"Id":396828,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"24385005878"},{"Id":396829,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"24385006003"},{"Id":396830,"FormularyType":"OHP","DrugName":"GNP ELECTROL SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"24385009647"},{"Id":396831,"FormularyType":"OHP","DrugName":"GNP ELECTROL SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"24385010047"},{"Id":396832,"FormularyType":"OHP","DrugName":"GNP ELECTROL SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"24385010347"},{"Id":396833,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"24385010680"},{"Id":396834,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 3 DAY","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"24385011009"},{"Id":396835,"FormularyType":"OHP","DrugName":"FIBER-CAPS TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"24385012576"},{"Id":396836,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"24385014303"},{"Id":396837,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"24385019003"},{"Id":396838,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"24385020501"},{"Id":396839,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"24385020503"},{"Id":396840,"FormularyType":"OHP","DrugName":"HYDROCORT/ CRE ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"24385027403"},{"Id":396841,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"24385027603"},{"Id":396842,"FormularyType":"OHP","DrugName":"GNP ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"24385027868"},{"Id":396843,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"24385029950"},{"Id":396844,"FormularyType":"OHP","DrugName":"GNP FIBER POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"24385030127"},{"Id":396845,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385036126"},{"Id":396846,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385036134"},{"Id":396847,"FormularyType":"OHP","DrugName":"GNP MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"24385036571"},{"Id":396848,"FormularyType":"OHP","DrugName":"GNP MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"24385036578"},{"Id":396849,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"24385036638"},{"Id":396850,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385037226"},{"Id":396851,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"24385037926"},{"Id":396852,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"24385044164"},{"Id":396853,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"24385047152"},{"Id":396854,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"24385047161"},{"Id":396855,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"24385047178"},{"Id":396856,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"24385047199"},{"Id":396857,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"24385047847"},{"Id":396858,"FormularyType":"OHP","DrugName":"GNP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"24385047978"},{"Id":396859,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"24385048447"},{"Id":396860,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"24385048471"},{"Id":396861,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"24385048478"},{"Id":396862,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"24385048490"},{"Id":396863,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"24385048547"},{"Id":396864,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"24385052403"},{"Id":396865,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"24385052405"},{"Id":396866,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"24385053126"},{"Id":396867,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"24385055010"},{"Id":396868,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"24385059029"},{"Id":396869,"FormularyType":"OHP","DrugName":"GNP ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"24385059523"},{"Id":396870,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"24385059871"},{"Id":396871,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"24385060471"},{"Id":396872,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"24385060478"},{"Id":396873,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"24385060485"},{"Id":396874,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"24385060602"},{"Id":396875,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"24385064771"},{"Id":396876,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"24385064778"},{"Id":396877,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385090526"},{"Id":396878,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"24385090534"},{"Id":396879,"FormularyType":"OHP","DrugName":"GNP ALL DAY TAB ALLERGY","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"24385099865"},{"Id":396880,"FormularyType":"OHP","DrugName":"GNP ALL DAY TAB ALLERGY","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"24385099874"},{"Id":396881,"FormularyType":"OHP","DrugName":"GNP ALL DAY TAB ALLERGY","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"24385099875"},{"Id":396882,"FormularyType":"OHP","DrugName":"BP WASH LIQ 5%","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"24470090004"},{"Id":396883,"FormularyType":"OHP","DrugName":"BP WASH LIQ 5%","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"24470090008"},{"Id":396884,"FormularyType":"OHP","DrugName":"BP WASH LIQ 10%","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"24470090108"},{"Id":396885,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"24470092360"},{"Id":396886,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"24470093901"},{"Id":396887,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"24470093903"},{"Id":396888,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"24470093907"},{"Id":396889,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"24470094010"},{"Id":396890,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"24470094050"},{"Id":396891,"FormularyType":"OHP","DrugName":"UREA LOT 40%","DosageForm":"LOTN - Lotion","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080004140","GenericName":"UREA LOTION 40%","NDC":"24470096208"},{"Id":396892,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117040","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","NDC":"24658017230"},{"Id":396893,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117050","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","NDC":"24658017330"},{"Id":396894,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117060","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","NDC":"24658017430"},{"Id":396895,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"24658026005"},{"Id":396896,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"24658026018"},{"Id":396897,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"24658026060"},{"Id":396898,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"24658026105"},{"Id":396899,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"24658026190"},{"Id":396900,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"24658026205"},{"Id":396901,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"24658026245"},{"Id":396902,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"24658026290"},{"Id":396903,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"24658026305"},{"Id":396904,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"24658026345"},{"Id":396905,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"24658026390"},{"Id":396906,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"24658026405"},{"Id":396907,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"24658026430"},{"Id":396908,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"24658026445"},{"Id":396909,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"24658026693"},{"Id":396910,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"24658026695"},{"Id":396911,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"24658027095"},{"Id":396912,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"24658027197"},{"Id":396913,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031001"},{"Id":396914,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031005"},{"Id":396915,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031007"},{"Id":396916,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031008"},{"Id":396917,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031010"},{"Id":396918,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031020"},{"Id":396919,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031021"},{"Id":396920,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031030"},{"Id":396921,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"24658031050"},{"Id":396922,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 420MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117070","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 420 MG","NDC":"24658034690"},{"Id":396923,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"24658050010"},{"Id":396924,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"24658050030"},{"Id":396925,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"24658050090"},{"Id":396926,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"24658050110"},{"Id":396927,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"24658050130"},{"Id":396928,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"24658050145"},{"Id":396929,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"24658050190"},{"Id":396930,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"24658050210"},{"Id":396931,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"24658050230"},{"Id":396932,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"24658050245"},{"Id":396933,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"24658050290"},{"Id":396934,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"24658050310"},{"Id":396935,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"24658050330"},{"Id":396936,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"24658050345"},{"Id":396937,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"24658050390"},{"Id":396938,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"24658050410"},{"Id":396939,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"24658050430"},{"Id":396940,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"24658050445"},{"Id":396941,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"24658050490"},{"Id":396942,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"24658050710"},{"Id":396943,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"24658050790"},{"Id":396944,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"24658050810"},{"Id":396945,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"24658050890"},{"Id":396946,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"24658050910"},{"Id":396947,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"24658050990"},{"Id":396948,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"24658051010"},{"Id":396949,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"24658051090"},{"Id":396950,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000303","GenericName":"ESTRADIOL TAB 0.5 MG","NDC":"24658070201"},{"Id":396951,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"24658070301"},{"Id":396952,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"24658070305"},{"Id":396953,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"24658070401"},{"Id":396954,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"24658070405"},{"Id":396955,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"24658070632"},{"Id":396956,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"24658070733"},{"Id":396957,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"24658070834"},{"Id":396958,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"24658073001"},{"Id":396959,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"24658076016"},{"Id":396960,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"24658077005"},{"Id":396961,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"24658077105"},{"Id":396962,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"24658078001"},{"Id":396963,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"24658078105"},{"Id":396964,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"24658078210"},{"Id":396965,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"24658078310"},{"Id":396966,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"24658079001"},{"Id":396967,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000105","GenericName":"RIFAMPIN CAP 150 MG","NDC":"24658080130"},{"Id":396968,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"24658080260"},{"Id":396969,"FormularyType":"OHP","DrugName":"DOCUSATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"24689013001"},{"Id":396970,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"24689013201"},{"Id":396971,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"24689013701"},{"Id":396972,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"24689013901"},{"Id":396973,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"24689014002"},{"Id":396974,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"24689014102"},{"Id":396975,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"24689014105"},{"Id":396976,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"24689014202"},{"Id":396977,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"24689014205"},{"Id":396978,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"24689014301"},{"Id":396979,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"24689014601"},{"Id":396980,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"24689079201"},{"Id":396981,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"24689079210"},{"Id":396982,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"24689085501"},{"Id":396983,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"24689085510"},{"Id":396984,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"24689088201"},{"Id":396985,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"24689088210"},{"Id":396986,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"24689096101"},{"Id":396987,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"24689096110"},{"Id":396988,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"24979000901"},{"Id":396989,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"24979000912"},{"Id":396990,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"24979001001"},{"Id":396991,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"24979001012"},{"Id":396992,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"24979001101"},{"Id":396993,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"24979001112"},{"Id":396994,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"24979002602"},{"Id":396995,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"24979002607"},{"Id":396996,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"24979002702"},{"Id":396997,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"24979002707"},{"Id":396998,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"24979002802"},{"Id":396999,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"24979002807"},{"Id":397000,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"24979002902"},{"Id":397001,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"24979002907"},{"Id":397002,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"24979003007"},{"Id":397003,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"24979012721"},{"Id":397004,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"24979012804"},{"Id":397005,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"24979013201"},{"Id":397006,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"24979013301"},{"Id":397007,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"24979018101"},{"Id":397008,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"24979018201"},{"Id":397009,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"24979018301"},{"Id":397010,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"24979019801"},{"Id":397011,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"24979019901"},{"Id":397012,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"24979020001"},{"Id":397013,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"24979020003"},{"Id":397014,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"24979020101"},{"Id":397015,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"24979020103"},{"Id":397016,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006820","GenericName":"TOPIRAMATE SPRINKLE CAP 15 MG","NDC":"24979021004"},{"Id":397017,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 25MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006830","GenericName":"TOPIRAMATE SPRINKLE CAP 25 MG","NDC":"24979021104"},{"Id":397018,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"24979022901"},{"Id":397019,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"24979022903"},{"Id":397020,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"24979023001"},{"Id":397021,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"24979023003"},{"Id":397022,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"24979023101"},{"Id":397023,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"24979023102"},{"Id":397024,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"24979023103"},{"Id":397025,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000445","GenericName":"POTASSIUM CHLORIDE TAB ER 20 MEQ (1500 MG)","NDC":"24979023201"},{"Id":397026,"FormularyType":"OHP","DrugName":"SORAFENIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533060400320","GenericName":"SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"24979071544"},{"Id":397027,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100320","GenericName":"GALANTAMINE HYDROBROMIDE TAB 4 MG","NDC":"24979072204"},{"Id":397028,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100330","GenericName":"GALANTAMINE HYDROBROMIDE TAB 8 MG","NDC":"24979072304"},{"Id":397029,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100340","GenericName":"GALANTAMINE HYDROBROMIDE TAB 12 MG","NDC":"24979072404"},{"Id":397030,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"24979072606"},{"Id":397031,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"24979072607"},{"Id":397032,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"25000012112"},{"Id":397033,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"25000012212"},{"Id":397034,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"25000012312"},{"Id":397035,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"25021000102"},{"Id":397036,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"25021000202"},{"Id":397037,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"25021000205"},{"Id":397038,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"25021000610"},{"Id":397039,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"25021000805"},{"Id":397040,"FormularyType":"OHP","DrugName":"TRIAMCINOLON INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"25021005401"},{"Id":397041,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102110","GenericName":"CEFAZOLIN SODIUM FOR INJ 500 MG","NDC":"25021010010"},{"Id":397042,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"25021010610"},{"Id":397043,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"25021010720"},{"Id":397044,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"25021010910"},{"Id":397045,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"25021011020"},{"Id":397046,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102117","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 10 GM","NDC":"25021011199"},{"Id":397047,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 200MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112024","GenericName":"CIPROFLOXACIN 200 MG/100ML IN D5W","NDC":"25021011482"},{"Id":397048,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 400MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112028","GenericName":"CIPROFLOXACIN 400 MG/200ML IN D5W","NDC":"25021011487"},{"Id":397049,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 300/2ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020302031","GenericName":"CLINDAMYCIN PHOSPHATE INJ 300 MG/2ML","NDC":"25021011502"},{"Id":397050,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 600/4ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020302032","GenericName":"CLINDAMYCIN PHOSPHATE INJ 600 MG/4ML","NDC":"25021011504"},{"Id":397051,"FormularyType":"OHP","DrugName":"CLINDAMYCIN INJ 900/6ML","DosageForm":"SOLN - Solution","Strength":"900","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020302033","GenericName":"CLINDAMYCIN PHOSPHATE INJ 900 MG/6ML","NDC":"25021011506"},{"Id":397052,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102105","GenericName":"CEFUROXIME SODIUM FOR INJ 750 MG","NDC":"25021011810"},{"Id":397053,"FormularyType":"OHP","DrugName":"CEFUROXIME INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065102115","GenericName":"CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","NDC":"25021011920"},{"Id":397054,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"25021012120"},{"Id":397055,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"25021012250"},{"Id":397056,"FormularyType":"OHP","DrugName":"CEFTAZIDIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002110","GenericName":"CEFTAZIDIME FOR INJ 1 GM","NDC":"25021012720"},{"Id":397057,"FormularyType":"OHP","DrugName":"CEFTAZIDIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002117","GenericName":"CEFTAZIDIME FOR IV SOLN 2 GM","NDC":"25021012850"},{"Id":397058,"FormularyType":"OHP","DrugName":"CEFTAZIDIME INJ 6GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"6","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002120","GenericName":"CEFTAZIDIME FOR INJ 6 GM","NDC":"25021012999"},{"Id":397059,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"25021013182"},{"Id":397060,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"25021013281"},{"Id":397061,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"25021013282"},{"Id":397062,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"25021013283"},{"Id":397063,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"25021013610"},{"Id":397064,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"25021013720"},{"Id":397065,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"25021014220"},{"Id":397066,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"25021014330"},{"Id":397067,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"25021014499"},{"Id":397068,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"25021014720"},{"Id":397069,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"25021014830"},{"Id":397070,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"25021014930"},{"Id":397071,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"25021015010"},{"Id":397072,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"25021015120"},{"Id":397073,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"25021015320"},{"Id":397074,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 20MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"20000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102135","GenericName":"PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","NDC":"25021015451"},{"Id":397075,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"25021015799"},{"Id":397076,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"25021015899"},{"Id":397077,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"25021016020"},{"Id":397078,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"25021016130"},{"Id":397079,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"25021017302"},{"Id":397080,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"25021017304"},{"Id":397081,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"25021018010"},{"Id":397082,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"25021018066"},{"Id":397083,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"25021018199"},{"Id":397084,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"25021018466"},{"Id":397085,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"25021018467"},{"Id":397086,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"25021018482"},{"Id":397087,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"25021018487"},{"Id":397088,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 200MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112024","GenericName":"CIPROFLOXACIN 200 MG/100ML IN D5W","NDC":"25021019282"},{"Id":397089,"FormularyType":"OHP","DrugName":"CIPROFLOXACN INJ 400MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020112028","GenericName":"CIPROFLOXACIN 400 MG/200ML IN D5W","NDC":"25021019287"},{"Id":397090,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"25021019799"},{"Id":397091,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"25021019899"},{"Id":397092,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"25021019920"},{"Id":397093,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"25021019966"},{"Id":397094,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"25021030167"},{"Id":397095,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"25021030168"},{"Id":397096,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"25021031102"},{"Id":397097,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"25021031104"},{"Id":397098,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"25021031110"},{"Id":397099,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"25021031202"},{"Id":397100,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"25021031204"},{"Id":397101,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"25021031802"},{"Id":397102,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"25021031804"},{"Id":397103,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"25021032002"},{"Id":397104,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"25021032004"},{"Id":397105,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"25021032010"},{"Id":397106,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"25021032104"},{"Id":397107,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"25021032110"},{"Id":397108,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"25021032210"},{"Id":397109,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1GM/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102020","GenericName":"PROCAINAMIDE HCL INJ 500 MG/ML","NDC":"25021032302"},{"Id":397110,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"25021040001"},{"Id":397111,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"25021040010"},{"Id":397112,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"25021040030"},{"Id":397113,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"25021040066"},{"Id":397114,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"25021040067"},{"Id":397115,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"25021040068"},{"Id":397116,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"25021040201"},{"Id":397117,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"25021040210"},{"Id":397118,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"25021040266"},{"Id":397119,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"25021040301"},{"Id":397120,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"25021040304"},{"Id":397121,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"25021040366"},{"Id":397122,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"25021040401"},{"Id":397123,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"25021041070"},{"Id":397124,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"25021041071"},{"Id":397125,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"25021041076"},{"Id":397126,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"25021041077"},{"Id":397127,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"25021041078"},{"Id":397128,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"25021041170"},{"Id":397129,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"25021041171"},{"Id":397130,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"25021046001"},{"Id":397131,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 40/10ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"25021046110"},{"Id":397132,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"25021046401"},{"Id":397133,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102030","GenericName":"OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML)","NDC":"25021046705"},{"Id":397134,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"25021046810"},{"Id":397135,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 200MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102107","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 200 MCG","NDC":"25021046910"},{"Id":397136,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 500MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102112","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 500 MCG","NDC":"25021047010"},{"Id":397137,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"25021048101"},{"Id":397138,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"25021050201"},{"Id":397139,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"25021060103"},{"Id":397140,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"25021060203"},{"Id":397141,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"25021066110"},{"Id":397142,"FormularyType":"OHP","DrugName":"GLYDO GEL 2%","DosageForm":"PRSY - Prefilled Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9085006010E420","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","NDC":"25021067376"},{"Id":397143,"FormularyType":"OHP","DrugName":"GLYDO GEL 2%","DosageForm":"PRSY - Prefilled Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9085006010E420","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","NDC":"25021067377"},{"Id":397144,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"25021079120"},{"Id":397145,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"25021079802"},{"Id":397146,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"25021079810"},{"Id":397147,"FormularyType":"OHP","DrugName":"HLTHY ACCNTS LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"25439093515"},{"Id":397148,"FormularyType":"OHP","DrugName":"HLTHY ACCNTS LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"25439093516"},{"Id":397149,"FormularyType":"OHP","DrugName":"HLTHY ACCNTS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"25439093518"},{"Id":397150,"FormularyType":"OHP","DrugName":"HLTHY ACCNTS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"25439093519"},{"Id":397151,"FormularyType":"OHP","DrugName":"HLTHY ACCNTS LIQ STRWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"25439093520"},{"Id":397152,"FormularyType":"OHP","DrugName":"VOYDEYA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85808520000320","GenericName":"DANICOPAN TAB 100 MG","NDC":"25682004392"},{"Id":397153,"FormularyType":"OHP","DrugName":"VOYDEYA TAB 50-100MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8580852000B720","GenericName":"DANICOPAN TAB THERAPY PACK 50 MG & 100 MG","NDC":"25682004692"},{"Id":397154,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"27241001531"},{"Id":397155,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"27241002168"},{"Id":397156,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"27241002238"},{"Id":397157,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"27241004011"},{"Id":397158,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"27241004021"},{"Id":397159,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"27241004910"},{"Id":397160,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"27241006203"},{"Id":397161,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"27241006303"},{"Id":397162,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"27241007006"},{"Id":397163,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"27241007105"},{"Id":397164,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"27241007106"},{"Id":397165,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"27241011603"},{"Id":397166,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"27241011703"},{"Id":397167,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"27241011705"},{"Id":397168,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"27241011804"},{"Id":397169,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"27241011904"},{"Id":397170,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"27241012004"},{"Id":397171,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"27241012302"},{"Id":397172,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"27241012403"},{"Id":397173,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"27241012405"},{"Id":397174,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"27241012502"},{"Id":397175,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"27241012505"},{"Id":397176,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"27241012602"},{"Id":397177,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"27241012605"},{"Id":397178,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"27241013421"},{"Id":397179,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"27241013436"},{"Id":397180,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"27241013451"},{"Id":397181,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"27241013909"},{"Id":397182,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"27241015504"},{"Id":397183,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"27241015508"},{"Id":397184,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"27241015604"},{"Id":397185,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"27241015608"},{"Id":397186,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"27241015704"},{"Id":397187,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"27241015860"},{"Id":397188,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"27241015919"},{"Id":397189,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"27241016001"},{"Id":397190,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"27241016010"},{"Id":397191,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"27241016101"},{"Id":397192,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"27241016201"},{"Id":397193,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"27241016301"},{"Id":397194,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"27241017356"},{"Id":397195,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"27241017456"},{"Id":397196,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"27241018757"},{"Id":397197,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"27241019105"},{"Id":397198,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"27241019130"},{"Id":397199,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"27241019190"},{"Id":397200,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"27241019205"},{"Id":397201,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"27241019230"},{"Id":397202,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"27241019290"},{"Id":397203,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"27241021601"},{"Id":397204,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"27241021701"},{"Id":397205,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"27241024201"},{"Id":397206,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"27241024301"},{"Id":397207,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"27241024949"},{"Id":397208,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"27241028601"},{"Id":397209,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"27241028701"},{"Id":397210,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"27241028801"},{"Id":397211,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"27241028901"},{"Id":397212,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"27241029001"},{"Id":397213,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"27241029101"},{"Id":397214,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200310","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","NDC":"27241030101"},{"Id":397215,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200320","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"27241030201"},{"Id":397216,"FormularyType":"OHP","DrugName":"XOPENEX HFA AER","DosageForm":"AERO - Aerosol","Strength":"45","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201045503220","GenericName":"LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV)","NDC":"27437005601"},{"Id":397217,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"27808003501"},{"Id":397218,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"27808003502"},{"Id":397219,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"27808003503"},{"Id":397220,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"27808003601"},{"Id":397221,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"27808003602"},{"Id":397222,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"27808003603"},{"Id":397223,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"27808003701"},{"Id":397224,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"27808003702"},{"Id":397225,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"27808003703"},{"Id":397226,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"27808005102"},{"Id":397227,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102020","GenericName":"METHYLPHENIDATE HCL SOLN 5 MG/5ML","NDC":"27808005801"},{"Id":397228,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102030","GenericName":"METHYLPHENIDATE HCL SOLN 10 MG/5ML","NDC":"27808005901"},{"Id":397229,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"27808008201"},{"Id":397230,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"27808008202"},{"Id":397231,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100320","GenericName":"DEXMETHYLPHENIDATE HCL TAB 2.5 MG","NDC":"27808009101"},{"Id":397232,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100330","GenericName":"DEXMETHYLPHENIDATE HCL TAB 5 MG","NDC":"27808009201"},{"Id":397233,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100340","GenericName":"DEXMETHYLPHENIDATE HCL TAB 10 MG","NDC":"27808009301"},{"Id":397234,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"27808015501"},{"Id":397235,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"27808015503"},{"Id":397236,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"27808015601"},{"Id":397237,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"27808015603"},{"Id":397238,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"27808015701"},{"Id":397239,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"27808015703"},{"Id":397240,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"27808015801"},{"Id":397241,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"27808015803"},{"Id":397242,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"27808020601"},{"Id":397243,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"27808020701"},{"Id":397244,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"27808023301"},{"Id":397245,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"27808023302"},{"Id":397246,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"27808023401"},{"Id":397247,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"27808023402"},{"Id":397248,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"27808023501"},{"Id":397249,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"27808023601"},{"Id":397250,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"27808023701"},{"Id":397251,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"27808023801"},{"Id":397252,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"27808023901"},{"Id":397253,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"27808024001"},{"Id":397254,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"27808024101"},{"Id":397255,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"27808024301"},{"Id":397256,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"27808024401"},{"Id":397257,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"27808024501"},{"Id":397258,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"27808024601"},{"Id":397259,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"27808026301"},{"Id":397260,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"27808026302"},{"Id":397261,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"27808026401"},{"Id":397262,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"27808026402"},{"Id":397263,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"27808026501"},{"Id":397264,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"27808026502"},{"Id":397265,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"27808026601"},{"Id":397266,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"27808029601"},{"Id":397267,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"27808029602"},{"Id":397268,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"27808029701"},{"Id":397269,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"27808029702"},{"Id":397270,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"27808030101"},{"Id":397271,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"27808030102"},{"Id":397272,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"27808030103"},{"Id":397273,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"27808030201"},{"Id":397274,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"27808030202"},{"Id":397275,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"27808030203"},{"Id":397276,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"27808030301"},{"Id":397277,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"27808030302"},{"Id":397278,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"27808030303"},{"Id":397279,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"27808030401"},{"Id":397280,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"27808030402"},{"Id":397281,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"27808030403"},{"Id":397282,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"27808030501"},{"Id":397283,"FormularyType":"OHP","DrugName":"ENTERADE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"28028035387"},{"Id":397284,"FormularyType":"OHP","DrugName":"ENTERADE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"28028035389"},{"Id":397285,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 400MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007540","GenericName":"THEOPHYLLINE TAB ER 24HR 400 MG","NDC":"29033000101"},{"Id":397286,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 600MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007560","GenericName":"THEOPHYLLINE TAB ER 24HR 600 MG","NDC":"29033000201"},{"Id":397287,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"29033000301"},{"Id":397288,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"29033000305"},{"Id":397289,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 300MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006930","GenericName":"CARBAMAZEPINE CAP ER 12HR 300 MG","NDC":"29033000412"},{"Id":397290,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 100MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006910","GenericName":"CARBAMAZEPINE CAP ER 12HR 100 MG","NDC":"29033001912"},{"Id":397291,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 200MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006920","GenericName":"CARBAMAZEPINE CAP ER 12HR 200 MG","NDC":"29033002012"},{"Id":397292,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"29033002602"},{"Id":397293,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000305","GenericName":"PINDOLOL TAB 5 MG","NDC":"29033002801"},{"Id":397294,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000310","GenericName":"PINDOLOL TAB 10 MG","NDC":"29033002901"},{"Id":397295,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"29033003001"},{"Id":397296,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"29033003601"},{"Id":397297,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"29033003630"},{"Id":397298,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"29033003730"},{"Id":397299,"FormularyType":"OHP","DrugName":"OXYCOD/ACETA SOL 5/325MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002202005","GenericName":"OXYCODONE W/ ACETAMINOPHEN SOLN 5-325 MG/5ML","NDC":"29033040535"},{"Id":397300,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"29033050034"},{"Id":397301,"FormularyType":"OHP","DrugName":"ENDUR-ACIN TAB 250MG SR","DosageForm":"TBCR - Tablet ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000440","GenericName":"NIACIN TAB ER 250 MG","NDC":"29135000001"},{"Id":397302,"FormularyType":"OHP","DrugName":"ENDUR-ACIN TAB 500MG SR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"29135000002"},{"Id":397303,"FormularyType":"OHP","DrugName":"ENDUR-ACIN TAB 750MG","DosageForm":"TBCR - Tablet ER","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000460","GenericName":"NIACIN TAB ER 750 MG","NDC":"29135016102"},{"Id":397304,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000340","GenericName":"NIACIN TAB 250 MG","NDC":"29135016801"},{"Id":397305,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"29135017001"},{"Id":397306,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"29300011505"},{"Id":397307,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"29300011510"},{"Id":397308,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"29300011516"},{"Id":397309,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"29300011605"},{"Id":397310,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"29300011610"},{"Id":397311,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"29300011616"},{"Id":397312,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"29300011705"},{"Id":397313,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"29300011710"},{"Id":397314,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"29300011716"},{"Id":397315,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"29300011805"},{"Id":397316,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"29300011810"},{"Id":397317,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"29300011816"},{"Id":397318,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"29300012401"},{"Id":397319,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"29300012410"},{"Id":397320,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"29300012501"},{"Id":397321,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"29300012510"},{"Id":397322,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"29300012601"},{"Id":397323,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"29300012613"},{"Id":397324,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"29300012701"},{"Id":397325,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"29300012713"},{"Id":397326,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"29300012801"},{"Id":397327,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"29300012810"},{"Id":397328,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"29300012901"},{"Id":397329,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"29300012910"},{"Id":397330,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"29300013001"},{"Id":397331,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"29300013005"},{"Id":397332,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"29300013010"},{"Id":397333,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000120","GenericName":"ZALEPLON CAP 5 MG","NDC":"29300013101"},{"Id":397334,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000130","GenericName":"ZALEPLON CAP 10 MG","NDC":"29300013201"},{"Id":397335,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"29300013601"},{"Id":397336,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"29300013605"},{"Id":397337,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"29300013610"},{"Id":397338,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"29300013701"},{"Id":397339,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"29300013705"},{"Id":397340,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"29300014419"},{"Id":397341,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"29300014519"},{"Id":397342,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"29300014619"},{"Id":397343,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"29300015501"},{"Id":397344,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"29300015519"},{"Id":397345,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"29300016810"},{"Id":397346,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"29300016815"},{"Id":397347,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"29300016903"},{"Id":397348,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"29300016910"},{"Id":397349,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"29300016915"},{"Id":397350,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"29300017105"},{"Id":397351,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"29300017116"},{"Id":397352,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"29300017205"},{"Id":397353,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"29300017216"},{"Id":397354,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"29300018701"},{"Id":397355,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"29300018705"},{"Id":397356,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"29300018713"},{"Id":397357,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"29300018801"},{"Id":397358,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"29300018805"},{"Id":397359,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"29300018813"},{"Id":397360,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"29300018901"},{"Id":397361,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"29300018905"},{"Id":397362,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"29300018913"},{"Id":397363,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"29300019010"},{"Id":397364,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"29300019019"},{"Id":397365,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"29300019110"},{"Id":397366,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"29300019119"},{"Id":397367,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"29300019210"},{"Id":397368,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"29300019219"},{"Id":397369,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"29300021213"},{"Id":397370,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"29300021219"},{"Id":397371,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"29300021313"},{"Id":397372,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"29300021319"},{"Id":397373,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"29300021413"},{"Id":397374,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"29300021419"},{"Id":397375,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"29300022010"},{"Id":397376,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"29300022013"},{"Id":397377,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"29300022019"},{"Id":397378,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"29300022110"},{"Id":397379,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"29300022113"},{"Id":397380,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"29300022119"},{"Id":397381,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"29300022210"},{"Id":397382,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"29300022213"},{"Id":397383,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"29300022219"},{"Id":397384,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"29300022601"},{"Id":397385,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"29300022605"},{"Id":397386,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"29300022652"},{"Id":397387,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"29300022701"},{"Id":397388,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"29300022705"},{"Id":397389,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"29300022746"},{"Id":397390,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"29300023213"},{"Id":397391,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"29300023319"},{"Id":397392,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"29300023419"},{"Id":397393,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"29300023519"},{"Id":397394,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"29300023916"},{"Id":397395,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"29300024016"},{"Id":397396,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB ODT 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025107210","GenericName":"DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG","NDC":"29300025011"},{"Id":397397,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB ODT 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025107210","GenericName":"DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG","NDC":"29300025087"},{"Id":397398,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB ODT 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025107220","GenericName":"DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG","NDC":"29300025111"},{"Id":397399,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB ODT 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025107220","GenericName":"DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG","NDC":"29300025187"},{"Id":397400,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"29300026881"},{"Id":397401,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"29300026891"},{"Id":397402,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"29300026981"},{"Id":397403,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"29300026991"},{"Id":397404,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"29300029616"},{"Id":397405,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"29300029716"},{"Id":397406,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100320","GenericName":"PRASUGREL HCL TAB 5 MG (BASE EQUIV)","NDC":"29300030113"},{"Id":397407,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100330","GenericName":"PRASUGREL HCL TAB 10 MG (BASE EQUIV)","NDC":"29300030213"},{"Id":397408,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"29300030613"},{"Id":397409,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"29300030713"},{"Id":397410,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"29300031621"},{"Id":397411,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"29300031681"},{"Id":397412,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"29300031721"},{"Id":397413,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"29300031781"},{"Id":397414,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"29300032813"},{"Id":397415,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"29300032819"},{"Id":397416,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"29300032913"},{"Id":397417,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"29300032919"},{"Id":397418,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"29300033301"},{"Id":397419,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"29300033401"},{"Id":397420,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"29300034301"},{"Id":397421,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"29300034310"},{"Id":397422,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"29300034401"},{"Id":397423,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"29300034410"},{"Id":397424,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"29300034901"},{"Id":397425,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"29300034905"},{"Id":397426,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"29300034910"},{"Id":397427,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"29300035001"},{"Id":397428,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"29300035005"},{"Id":397429,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"29300035010"},{"Id":397430,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"29300035101"},{"Id":397431,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"29300035110"},{"Id":397432,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"29300035201"},{"Id":397433,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"29300035210"},{"Id":397434,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"29300035301"},{"Id":397435,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"29300035310"},{"Id":397436,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"29300035401"},{"Id":397437,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"29300035410"},{"Id":397438,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"29300035501"},{"Id":397439,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"29300035505"},{"Id":397440,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"29300035510"},{"Id":397441,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"29300035905"},{"Id":397442,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"29300035916"},{"Id":397443,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"29300036416"},{"Id":397444,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"29300036516"},{"Id":397445,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"29300036616"},{"Id":397446,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"29300036716"},{"Id":397447,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"29300038201"},{"Id":397448,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"29300038210"},{"Id":397449,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"29300038901"},{"Id":397450,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"29300038905"},{"Id":397451,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"29300039605"},{"Id":397452,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"29300039610"},{"Id":397453,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"29300039619"},{"Id":397454,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"29300039705"},{"Id":397455,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"29300039710"},{"Id":397456,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"29300039719"},{"Id":397457,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"29300039805"},{"Id":397458,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"29300039810"},{"Id":397459,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"29300039819"},{"Id":397460,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"29300039901"},{"Id":397461,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100310","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","NDC":"29300040001"},{"Id":397462,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100320","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","NDC":"29300040101"},{"Id":397463,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"29300041001"},{"Id":397464,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"29300041005"},{"Id":397465,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"29300041010"},{"Id":397466,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"29300041101"},{"Id":397467,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"29300041105"},{"Id":397468,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"29300041110"},{"Id":397469,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"29300041201"},{"Id":397470,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"29300041205"},{"Id":397471,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"29300041210"},{"Id":397472,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"29300041301"},{"Id":397473,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"29300041305"},{"Id":397474,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"29300041319"},{"Id":397475,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"29300041501"},{"Id":397476,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"29300041510"},{"Id":397477,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"29300041519"},{"Id":397478,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"29300042801"},{"Id":397479,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"29300042901"},{"Id":397480,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"29300043001"},{"Id":397481,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"29300045801"},{"Id":397482,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"29300045901"},{"Id":397483,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"29300046801"},{"Id":397484,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"29300046805"},{"Id":397485,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"29300046810"},{"Id":397486,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"29300047401"},{"Id":397487,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"29300048501"},{"Id":397488,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"29300048510"},{"Id":397489,"FormularyType":"OHP","DrugName":"POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"99","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700005000310","GenericName":"POTASSIUM TAB 99 MG","NDC":"30768000405"},{"Id":397490,"FormularyType":"OHP","DrugName":"MELATONIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000310","GenericName":"MELATONIN TAB 300 MCG","NDC":"30768000541"},{"Id":397491,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"30768000676"},{"Id":397492,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"30768003304"},{"Id":397493,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"30768003545"},{"Id":397494,"FormularyType":"OHP","DrugName":"CALCIUM/VT D TAB 600-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640349","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-3.125 MCG (125 UNIT)","NDC":"30768003568"},{"Id":397495,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"30768003720"},{"Id":397496,"FormularyType":"OHP","DrugName":"FOLATE TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"30768004069"},{"Id":397497,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"30768012336"},{"Id":397498,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"30768012608"},{"Id":397499,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"30768015605"},{"Id":397500,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"30768015745"},{"Id":397501,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 1MG/ML","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000940","GenericName":"MELATONIN LIQUID 1 MG/ML","NDC":"30768016836"},{"Id":397502,"FormularyType":"OHP","DrugName":"FISH OIL CAP ODR LESS","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"30768016887"},{"Id":397503,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"30768016888"},{"Id":397504,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"30768017621"},{"Id":397505,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"30768019484"},{"Id":397506,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"30768019941"},{"Id":397507,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"30768019995"},{"Id":397508,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"30768027664"},{"Id":397509,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"30768029173"},{"Id":397510,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG TR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"30768029505"},{"Id":397511,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"30768030173"},{"Id":397512,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"30768041283"},{"Id":397513,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"30768048678"},{"Id":397514,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"30768050356"},{"Id":397515,"FormularyType":"OHP","DrugName":"MELATONIN LOZ 5MG","DosageForm":"LOZG - Lozenge","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536004750","GenericName":"MELATONIN SUBLINGUAL LOZENGE 5 MG","NDC":"30768052816"},{"Id":397516,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"30768053491"},{"Id":397517,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"30768053503"},{"Id":397518,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"30768060693"},{"Id":397519,"FormularyType":"OHP","DrugName":"DRAMAMINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"31248000198"},{"Id":397520,"FormularyType":"OHP","DrugName":"DRAMAMINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"31248000738"},{"Id":397521,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"31604000324"},{"Id":397522,"FormularyType":"OHP","DrugName":"B12 TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"31604000330"},{"Id":397523,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"31604001079"},{"Id":397524,"FormularyType":"OHP","DrugName":"VIT E D-ALPH CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"31604001170"},{"Id":397525,"FormularyType":"OHP","DrugName":"MELATONIN TAB EX STR","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"31604001190"},{"Id":397526,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"31604001212"},{"Id":397527,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"31604001237"},{"Id":397528,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"31604001274"},{"Id":397529,"FormularyType":"OHP","DrugName":"B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"31604001281"},{"Id":397530,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"31604001284"},{"Id":397531,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"31604001285"},{"Id":397532,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"31604001289"},{"Id":397533,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"31604001290"},{"Id":397534,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604001328"},{"Id":397535,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"31604001338"},{"Id":397536,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604001416"},{"Id":397537,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"31604001426"},{"Id":397538,"FormularyType":"OHP","DrugName":"MULTI PRENAT TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"31604001435"},{"Id":397539,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"31604001473"},{"Id":397540,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"31604001475"},{"Id":397541,"FormularyType":"OHP","DrugName":"MULTI PRENAT TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"31604001499"},{"Id":397542,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"31604001688"},{"Id":397543,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604001714"},{"Id":397544,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604001724"},{"Id":397545,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000360","GenericName":"POTASSIUM GLUCONATE TAB 550 MG (92 MG EQUIV K)","NDC":"31604001797"},{"Id":397546,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"31604001870"},{"Id":397547,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604001873"},{"Id":397548,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"31604001886"},{"Id":397549,"FormularyType":"OHP","DrugName":"KIDS VIT D3 CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"31604002438"},{"Id":397550,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"31604002511"},{"Id":397551,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"31604002516"},{"Id":397552,"FormularyType":"OHP","DrugName":"CALCIUM/VITD TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"31604002517"},{"Id":397553,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"31604002585"},{"Id":397554,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604002586"},{"Id":397555,"FormularyType":"OHP","DrugName":"FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"31604002603"},{"Id":397556,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"31604002604"},{"Id":397557,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"31604002612"},{"Id":397558,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"31604002621"},{"Id":397559,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604002631"},{"Id":397560,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604002657"},{"Id":397561,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"31604002659"},{"Id":397562,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"31604002662"},{"Id":397563,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"31604002663"},{"Id":397564,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604002664"},{"Id":397565,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"31604002665"},{"Id":397566,"FormularyType":"OHP","DrugName":"D3 KIDS CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"31604002668"},{"Id":397567,"FormularyType":"OHP","DrugName":"D3 KIDS CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"31604002669"},{"Id":397568,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"31604002671"},{"Id":397569,"FormularyType":"OHP","DrugName":"D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"31604002673"},{"Id":397570,"FormularyType":"OHP","DrugName":"D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"31604002674"},{"Id":397571,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"31604002675"},{"Id":397572,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"31604002676"},{"Id":397573,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"31604002677"},{"Id":397574,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"31604002678"},{"Id":397575,"FormularyType":"OHP","DrugName":"D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"31604002683"},{"Id":397576,"FormularyType":"OHP","DrugName":"D3 ADULT CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"31604002706"},{"Id":397577,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"31604002715"},{"Id":397578,"FormularyType":"OHP","DrugName":"B-12 TAB 2500MCG","DosageForm":"TABS - Tablet","Strength":"2500","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000340","GenericName":"CYANOCOBALAMIN TAB 2500 MCG","NDC":"31604002718"},{"Id":397579,"FormularyType":"OHP","DrugName":"SUPER B-COMP TAB VIT C/FA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"31604002727"},{"Id":397580,"FormularyType":"OHP","DrugName":"SUPER B-COMP TAB VIT C/FA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"31604002729"},{"Id":397581,"FormularyType":"OHP","DrugName":"B-12 TR TAB 1000 MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"31604002730"},{"Id":397582,"FormularyType":"OHP","DrugName":"B-12 TAB 1000 CR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"31604002731"},{"Id":397583,"FormularyType":"OHP","DrugName":"SUPER B-COMP TAB VIT C/FA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"31604002734"},{"Id":397584,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"31604002741"},{"Id":397585,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"31604002742"},{"Id":397586,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"31604002743"},{"Id":397587,"FormularyType":"OHP","DrugName":"PRENATAL MUL CAP +DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512018000109","GenericName":"*PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 27-0.8-228 MG***","NDC":"31604002749"},{"Id":397588,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604002755"},{"Id":397589,"FormularyType":"OHP","DrugName":"D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"31604002758"},{"Id":397590,"FormularyType":"OHP","DrugName":"PRENATAL MUL CAP +DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512018000109","GenericName":"*PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 27-0.8-228 MG***","NDC":"31604002766"},{"Id":397591,"FormularyType":"OHP","DrugName":"D3 EXTRA STR CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"31604002778"},{"Id":397592,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG TR","DosageForm":"TBCR - Tablet ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000440","GenericName":"NIACIN TAB ER 250 MG","NDC":"31604002782"},{"Id":397593,"FormularyType":"OHP","DrugName":"D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"31604002793"},{"Id":397594,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"31604002844"},{"Id":397595,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"31604002888"},{"Id":397596,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"31604002920"},{"Id":397597,"FormularyType":"OHP","DrugName":"B12 TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"31604002929"},{"Id":397598,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"31604003089"},{"Id":397599,"FormularyType":"OHP","DrugName":"B-12 TR TAB 1000 MCG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"31604003169"},{"Id":397600,"FormularyType":"OHP","DrugName":"MELATONIN TAB MAX STR","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"31604003223"},{"Id":397601,"FormularyType":"OHP","DrugName":"D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"31604004069"},{"Id":397602,"FormularyType":"OHP","DrugName":"D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"31604004070"},{"Id":397603,"FormularyType":"OHP","DrugName":"D3 2000 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"31604004071"},{"Id":397604,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"31604004073"},{"Id":397605,"FormularyType":"OHP","DrugName":"D3 EXTRA STR CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"31604004074"},{"Id":397606,"FormularyType":"OHP","DrugName":"PRENATAL/FA CAP +DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000125","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 27-0.8-200 MG***","NDC":"31604004077"},{"Id":397607,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"31604004080"},{"Id":397608,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"31604004135"},{"Id":397609,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"31604004216"},{"Id":397610,"FormularyType":"OHP","DrugName":"PRENATAL MUL CAP DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000125","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 27-0.8-200 MG***","NDC":"31604004218"},{"Id":397611,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"31604004251"},{"Id":397612,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"65","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"31604004252"},{"Id":397613,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"31604004293"},{"Id":397614,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"31604004295"},{"Id":397615,"FormularyType":"OHP","DrugName":"D3 MAX STR CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"31604004373"},{"Id":397616,"FormularyType":"OHP","DrugName":"FISH OIL CAP MINIS","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"31604004375"},{"Id":397617,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"31722000530"},{"Id":397618,"FormularyType":"OHP","DrugName":"ITRACONAZOLE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407035002020","GenericName":"ITRACONAZOLE ORAL SOLN 10 MG/ML","NDC":"31722000631"},{"Id":397619,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000310","GenericName":"ZAFIRLUKAST TAB 10 MG","NDC":"31722000760"},{"Id":397620,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000320","GenericName":"ZAFIRLUKAST TAB 20 MG","NDC":"31722000860"},{"Id":397621,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"31722000950"},{"Id":397622,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"31722001130"},{"Id":397623,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"31722001230"},{"Id":397624,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"31722001330"},{"Id":397625,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"31722001701"},{"Id":397626,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"31722001710"},{"Id":397627,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"31722001801"},{"Id":397628,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"31722001805"},{"Id":397629,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"31722001810"},{"Id":397630,"FormularyType":"OHP","DrugName":"DIATRIZOATE SOL 66-10%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94402015302050","GenericName":"DIATRIZOATE MEGLUMINE & SODIUM ORAL SOLN 66-10%","NDC":"31722001912"},{"Id":397631,"FormularyType":"OHP","DrugName":"DIATRIZOATE SOL 66-10%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94402015302050","GenericName":"DIATRIZOATE MEGLUMINE & SODIUM ORAL SOLN 66-10%","NDC":"31722001930"},{"Id":397632,"FormularyType":"OHP","DrugName":"DIATRIZOATE SOL 66-10%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94402015302050","GenericName":"DIATRIZOATE MEGLUMINE & SODIUM ORAL SOLN 66-10%","NDC":"31722001931"},{"Id":397633,"FormularyType":"OHP","DrugName":"DIATRIZOATE SOL 66-10%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94402015302050","GenericName":"DIATRIZOATE MEGLUMINE & SODIUM ORAL SOLN 66-10%","NDC":"31722001932"},{"Id":397634,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"31722002301"},{"Id":397635,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"31722002305"},{"Id":397636,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"31722002401"},{"Id":397637,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"31722002405"},{"Id":397638,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"31722002501"},{"Id":397639,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"31722002505"},{"Id":397640,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"31722002730"},{"Id":397641,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"31722002790"},{"Id":397642,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"31722002830"},{"Id":397643,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"31722002890"},{"Id":397644,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"31722003601"},{"Id":397645,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"31722003701"},{"Id":397646,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"31722003801"},{"Id":397647,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 12.5MG","DosageForm":"SUPP - Suppository","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105205","GenericName":"PROMETHAZINE HCL SUPPOS 12.5 MG","NDC":"31722004031"},{"Id":397648,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 12.5MG","DosageForm":"SUPP - Suppository","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105205","GenericName":"PROMETHAZINE HCL SUPPOS 12.5 MG","NDC":"31722004032"},{"Id":397649,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105210","GenericName":"PROMETHAZINE HCL SUPPOS 25 MG","NDC":"31722004131"},{"Id":397650,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105210","GenericName":"PROMETHAZINE HCL SUPPOS 25 MG","NDC":"31722004132"},{"Id":397651,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"31722004312"},{"Id":397652,"FormularyType":"OHP","DrugName":"SAPROPTERIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565100320","GenericName":"SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG","NDC":"31722004512"},{"Id":397653,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"31722004701"},{"Id":397654,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"31722004730"},{"Id":397655,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"31722004801"},{"Id":397656,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"31722004830"},{"Id":397657,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"31722004930"},{"Id":397658,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"31722004990"},{"Id":397659,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"31722005030"},{"Id":397660,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"31722005090"},{"Id":397661,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"31722005201"},{"Id":397662,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"31722005210"},{"Id":397663,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100320","GenericName":"IVABRADINE HCL TAB 5 MG (BASE EQUIV)","NDC":"31722005360"},{"Id":397664,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100330","GenericName":"IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","NDC":"31722005460"},{"Id":397665,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"31722006331"},{"Id":397666,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"31722006947"},{"Id":397667,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"31722007701"},{"Id":397668,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"31722007801"},{"Id":397669,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"31722007901"},{"Id":397670,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"31722007910"},{"Id":397671,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"31722008930"},{"Id":397672,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"31722009401"},{"Id":397673,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"31722009405"},{"Id":397674,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"31722009410"},{"Id":397675,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"31722009501"},{"Id":397676,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"31722009505"},{"Id":397677,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"31722009601"},{"Id":397678,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"31722009605"},{"Id":397679,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"31722010330"},{"Id":397680,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"31722010430"},{"Id":397681,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"31722010530"},{"Id":397682,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"31722012805"},{"Id":397683,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"31722012860"},{"Id":397684,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"31722012901"},{"Id":397685,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"31722013001"},{"Id":397686,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"31722013130"},{"Id":397687,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"31722013190"},{"Id":397688,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"31722013201"},{"Id":397689,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"31722013301"},{"Id":397690,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"31722013305"},{"Id":397691,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"31722013501"},{"Id":397692,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"31722013505"},{"Id":397693,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"31722013801"},{"Id":397694,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"31722013910"},{"Id":397695,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"31722014010"},{"Id":397696,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"31722014101"},{"Id":397697,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"31722014201"},{"Id":397698,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"31722014301"},{"Id":397699,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"31722014401"},{"Id":397700,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"31722014801"},{"Id":397701,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"31722014805"},{"Id":397702,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"31722014810"},{"Id":397703,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"31722014901"},{"Id":397704,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"31722014905"},{"Id":397705,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"31722015001"},{"Id":397706,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"31722015005"},{"Id":397707,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"31722015130"},{"Id":397708,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"31722015290"},{"Id":397709,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"31722015390"},{"Id":397710,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"31722015490"},{"Id":397711,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"31722015501"},{"Id":397712,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"31722015601"},{"Id":397713,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"31722015701"},{"Id":397714,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"31722015801"},{"Id":397715,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"31722015901"},{"Id":397716,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"31722016005"},{"Id":397717,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"31722016110"},{"Id":397718,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"31722016205"},{"Id":397719,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"31722016301"},{"Id":397720,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"31722016401"},{"Id":397721,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"31722016601"},{"Id":397722,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"31722016605"},{"Id":397723,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"31722016701"},{"Id":397724,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"31722016705"},{"Id":397725,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"31722017201"},{"Id":397726,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"31722017205"},{"Id":397727,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"31722017301"},{"Id":397728,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"31722017401"},{"Id":397729,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"31722017501"},{"Id":397730,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"31722017601"},{"Id":397731,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"31722017610"},{"Id":397732,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"31722017701"},{"Id":397733,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"31722017710"},{"Id":397734,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"31722017801"},{"Id":397735,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"31722017810"},{"Id":397736,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"31722017901"},{"Id":397737,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"31722017905"},{"Id":397738,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"31722018001"},{"Id":397739,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"31722018010"},{"Id":397740,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"31722018105"},{"Id":397741,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"31722018160"},{"Id":397742,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"31722018205"},{"Id":397743,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"31722018260"},{"Id":397744,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"31722018305"},{"Id":397745,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"31722018360"},{"Id":397746,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"31722018405"},{"Id":397747,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"31722018460"},{"Id":397748,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"31722018501"},{"Id":397749,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"31722018601"},{"Id":397750,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"31722018701"},{"Id":397751,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"31722018801"},{"Id":397752,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"31722018901"},{"Id":397753,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"31722019050"},{"Id":397754,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"31722019201"},{"Id":397755,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"31722019205"},{"Id":397756,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"31722019301"},{"Id":397757,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"31722019305"},{"Id":397758,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"31722019401"},{"Id":397759,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"31722019405"},{"Id":397760,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"31722019501"},{"Id":397761,"FormularyType":"OHP","DrugName":"OXYCODONE CON 100/5ML","DosageForm":"CONC - Concentrate","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075101320","GenericName":"OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML)","NDC":"31722019831"},{"Id":397762,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"31722020320"},{"Id":397763,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"31722020331"},{"Id":397764,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"31722020332"},{"Id":397765,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"31722020333"},{"Id":397766,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"31722021010"},{"Id":397767,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"31722021110"},{"Id":397768,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"31722021133"},{"Id":397769,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107020","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","NDC":"31722022901"},{"Id":397770,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107030","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","NDC":"31722023001"},{"Id":397771,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107035","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","NDC":"31722023101"},{"Id":397772,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107040","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","NDC":"31722023201"},{"Id":397773,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107045","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","NDC":"31722023301"},{"Id":397774,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107050","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","NDC":"31722023401"},{"Id":397775,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 35MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107055","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","NDC":"31722023501"},{"Id":397776,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 40MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107060","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 40 MG","NDC":"31722023601"},{"Id":397777,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"31722025201"},{"Id":397778,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"31722025205"},{"Id":397779,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"31722025210"},{"Id":397780,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"31722025301"},{"Id":397781,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"31722025305"},{"Id":397782,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"31722025310"},{"Id":397783,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"31722025728"},{"Id":397784,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"31722025828"},{"Id":397785,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"31722025928"},{"Id":397786,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"31722026021"},{"Id":397787,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"31722026121"},{"Id":397788,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"31722026221"},{"Id":397789,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"31722026330"},{"Id":397790,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"31722026430"},{"Id":397791,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"31722026530"},{"Id":397792,"FormularyType":"OHP","DrugName":"VORICONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407080001920","GenericName":"VORICONAZOLE FOR SUSP 40 MG/ML","NDC":"31722026631"},{"Id":397793,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"31722027805"},{"Id":397794,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"31722027905"},{"Id":397795,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"31722028410"},{"Id":397796,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"31722028490"},{"Id":397797,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"31722028510"},{"Id":397798,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"31722028590"},{"Id":397799,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"31722028610"},{"Id":397800,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"31722028690"},{"Id":397801,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"31722028710"},{"Id":397802,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"31722028790"},{"Id":397803,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"31722028810"},{"Id":397804,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"31722028890"},{"Id":397805,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"31722028910"},{"Id":397806,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"31722028990"},{"Id":397807,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"31722029010"},{"Id":397808,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"31722029090"},{"Id":397809,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"31722029110"},{"Id":397810,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"31722029190"},{"Id":397811,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"31722029210"},{"Id":397812,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"31722029290"},{"Id":397813,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"31722029310"},{"Id":397814,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"31722029390"},{"Id":397815,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"31722029410"},{"Id":397816,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"31722029490"},{"Id":397817,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"31722029510"},{"Id":397818,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"31722029590"},{"Id":397819,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"31722029690"},{"Id":397820,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"31722029730"},{"Id":397821,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 0.5GM","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100110","GenericName":"ICOSAPENT ETHYL CAP 0.5 GM","NDC":"31722029824"},{"Id":397822,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"31722029912"},{"Id":397823,"FormularyType":"OHP","DrugName":"ELTROMBOPAG POW 12.5MG","DosageForm":"PACK - Packet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030103030","GenericName":"ELTROMBOPAG OLAMINE POWDER PACK FOR SUSP 12.5 MG (BASE EQ)","NDC":"31722030032"},{"Id":397824,"FormularyType":"OHP","DrugName":"ELTROMBOPAG POW 25MG","DosageForm":"PACK - Packet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030103020","GenericName":"ELTROMBOPAG OLAMINE POWDER PACK FOR SUSP 25 MG (BASE EQUIV)","NDC":"31722030132"},{"Id":397825,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"31722030931"},{"Id":397826,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"31722030932"},{"Id":397827,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"31722031031"},{"Id":397828,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"31722031032"},{"Id":397829,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"31722031110"},{"Id":397830,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"31722031131"},{"Id":397831,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"31722031631"},{"Id":397832,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"31722035001"},{"Id":397833,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"31722035101"},{"Id":397834,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"31722035201"},{"Id":397835,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"31722035301"},{"Id":397836,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"31722035401"},{"Id":397837,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"31722035501"},{"Id":397838,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"31722035601"},{"Id":397839,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"31722036831"},{"Id":397840,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"31722036832"},{"Id":397841,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"31722036910"},{"Id":397842,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"31722036932"},{"Id":397843,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"31722038101"},{"Id":397844,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"31722038105"},{"Id":397845,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"31722038201"},{"Id":397846,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"31722038205"},{"Id":397847,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"31722038210"},{"Id":397848,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"31722038301"},{"Id":397849,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"31722038305"},{"Id":397850,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"31722038310"},{"Id":397851,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"31722041114"},{"Id":397852,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"31722041131"},{"Id":397853,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"31722041214"},{"Id":397854,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"31722041231"},{"Id":397855,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"31722041314"},{"Id":397856,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"31722041331"},{"Id":397857,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"31722041414"},{"Id":397858,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"31722041431"},{"Id":397859,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"31722041514"},{"Id":397860,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"31722041531"},{"Id":397861,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"31722041631"},{"Id":397862,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"31722042405"},{"Id":397863,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"31722042410"},{"Id":397864,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"31722042490"},{"Id":397865,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"31722042505"},{"Id":397866,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"31722042510"},{"Id":397867,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"31722042590"},{"Id":397868,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"31722042605"},{"Id":397869,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"31722042610"},{"Id":397870,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"31722042690"},{"Id":397871,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"31722042705"},{"Id":397872,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"31722042710"},{"Id":397873,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"31722042790"},{"Id":397874,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"31722044331"},{"Id":397875,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"31722044332"},{"Id":397876,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"31722044431"},{"Id":397877,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"31722044432"},{"Id":397878,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"31722046428"},{"Id":397879,"FormularyType":"OHP","DrugName":"EFAVIRENZ TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109030000330","GenericName":"EFAVIRENZ TAB 600 MG","NDC":"31722050430"},{"Id":397880,"FormularyType":"OHP","DrugName":"NEVIRAPINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050000320","GenericName":"NEVIRAPINE TAB 200 MG","NDC":"31722050560"},{"Id":397881,"FormularyType":"OHP","DrugName":"LAMIVUD/ZIDO TAB 150-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902500320","GenericName":"LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG","NDC":"31722050660"},{"Id":397882,"FormularyType":"OHP","DrugName":"ZIDOVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108085000330","GenericName":"ZIDOVUDINE TAB 300 MG","NDC":"31722050960"},{"Id":397883,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"31722051010"},{"Id":397884,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"31722051090"},{"Id":397885,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"31722051110"},{"Id":397886,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"31722051190"},{"Id":397887,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"31722051210"},{"Id":397888,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"31722051290"},{"Id":397889,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"31722051310"},{"Id":397890,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"31722051390"},{"Id":397891,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"31722051490"},{"Id":397892,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"31722051901"},{"Id":397893,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"31722052001"},{"Id":397894,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"31722052010"},{"Id":397895,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"31722052101"},{"Id":397896,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"31722052110"},{"Id":397897,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"31722052201"},{"Id":397898,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"31722052205"},{"Id":397899,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"31722052501"},{"Id":397900,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"31722052510"},{"Id":397901,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"31722052530"},{"Id":397902,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"31722052590"},{"Id":397903,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"31722052630"},{"Id":397904,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"31722052690"},{"Id":397905,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"31722052901"},{"Id":397906,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"31722053001"},{"Id":397907,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"31722053101"},{"Id":397908,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"31722053201"},{"Id":397909,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"31722053301"},{"Id":397910,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"31722053305"},{"Id":397911,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"31722053401"},{"Id":397912,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"31722053405"},{"Id":397913,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"31722053530"},{"Id":397914,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"31722053605"},{"Id":397915,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"31722053612"},{"Id":397916,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"31722053705"},{"Id":397917,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"31722053712"},{"Id":397918,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"31722053805"},{"Id":397919,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"31722053812"},{"Id":397920,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"31722053960"},{"Id":397921,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"31722054201"},{"Id":397922,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"31722054210"},{"Id":397923,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000110","GenericName":"INDOMETHACIN CAP 50 MG","NDC":"31722054301"},{"Id":397924,"FormularyType":"OHP","DrugName":"LOPIN/RITON TAB 200-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902550320","GenericName":"LOPINAVIR-RITONAVIR TAB 200-50 MG","NDC":"31722055612"},{"Id":397925,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"31722055760"},{"Id":397926,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"31722056030"},{"Id":397927,"FormularyType":"OHP","DrugName":"ABACAVIR SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005102020","GenericName":"ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV)","NDC":"31722056224"},{"Id":397928,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"31722056501"},{"Id":397929,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"31722056560"},{"Id":397930,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"31722056860"},{"Id":397931,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"31722057030"},{"Id":397932,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"31722057090"},{"Id":397933,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"31722057105"},{"Id":397934,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"31722057130"},{"Id":397935,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"31722057190"},{"Id":397936,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"31722057447"},{"Id":397937,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000320","GenericName":"MARAVIROC TAB 150 MG","NDC":"31722057960"},{"Id":397938,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000330","GenericName":"MARAVIROC TAB 300 MG","NDC":"31722058060"},{"Id":397939,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"31722058901"},{"Id":397940,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"31722058905"},{"Id":397941,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"31722058910"},{"Id":397942,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"31722059001"},{"Id":397943,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"31722059005"},{"Id":397944,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"31722059010"},{"Id":397945,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"31722059101"},{"Id":397946,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"31722059105"},{"Id":397947,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"31722059110"},{"Id":397948,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"31722059201"},{"Id":397949,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"31722059205"},{"Id":397950,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"31722059210"},{"Id":397951,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"31722059590"},{"Id":397952,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"31722059690"},{"Id":397953,"FormularyType":"OHP","DrugName":"RITONAVIR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104560000320","GenericName":"RITONAVIR TAB 100 MG","NDC":"31722059730"},{"Id":397954,"FormularyType":"OHP","DrugName":"LOPIN/RITON TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902550310","GenericName":"LOPINAVIR-RITONAVIR TAB 100-25 MG","NDC":"31722060360"},{"Id":397955,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"31722060730"},{"Id":397956,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"31722060830"},{"Id":397957,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"31722061005"},{"Id":397958,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"31722061090"},{"Id":397959,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"31722061105"},{"Id":397960,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"31722061190"},{"Id":397961,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"31722061205"},{"Id":397962,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"31722061290"},{"Id":397963,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"31722061305"},{"Id":397964,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"31722061390"},{"Id":397965,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"31722061405"},{"Id":397966,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"31722061490"},{"Id":397967,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"31722061505"},{"Id":397968,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"31722061590"},{"Id":397969,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"31722061605"},{"Id":397970,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"31722061690"},{"Id":397971,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"31722061705"},{"Id":397972,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"31722061790"},{"Id":397973,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"31722062131"},{"Id":397974,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"31722062132"},{"Id":397975,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"31722062160"},{"Id":397976,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"31722062231"},{"Id":397977,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"31722062232"},{"Id":397978,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"31722062260"},{"Id":397979,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"31722062330"},{"Id":397980,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"31722062390"},{"Id":397981,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"31722062726"},{"Id":397982,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"31722062805"},{"Id":397983,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"31722062830"},{"Id":397984,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"31722062890"},{"Id":397985,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"31722062921"},{"Id":397986,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"31722063031"},{"Id":397987,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"31722063131"},{"Id":397988,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"31722063231"},{"Id":397989,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"31722063901"},{"Id":397990,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"31722064001"},{"Id":397991,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"31722064730"},{"Id":397992,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200130","GenericName":"ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV)","NDC":"31722065360"},{"Id":397993,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200140","GenericName":"ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV)","NDC":"31722065460"},{"Id":397994,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200150","GenericName":"ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV)","NDC":"31722065530"},{"Id":397995,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"31722065731"},{"Id":397996,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"31722065832"},{"Id":397997,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"31722066410"},{"Id":397998,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"31722066430"},{"Id":397999,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"31722066490"},{"Id":398000,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"31722066510"},{"Id":398001,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"31722066530"},{"Id":398002,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"31722066590"},{"Id":398003,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"31722066631"},{"Id":398004,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"31722066632"},{"Id":398005,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"31722066660"},{"Id":398006,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"31722066860"},{"Id":398007,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"31722066960"},{"Id":398008,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"31722067318"},{"Id":398009,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"31722067360"},{"Id":398010,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"31722067418"},{"Id":398011,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"31722067460"},{"Id":398012,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"31722067518"},{"Id":398013,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"31722067560"},{"Id":398014,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"31722067631"},{"Id":398015,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"31722067632"},{"Id":398016,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"31722067635"},{"Id":398017,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"31722067636"},{"Id":398018,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"31722067760"},{"Id":398019,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"31722067856"},{"Id":398020,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"31722067956"},{"Id":398021,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP STARTER","DosageForm":"CDPK - CPDR Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240552500B320","GenericName":"DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG","NDC":"31722068060"},{"Id":398022,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"31722068147"},{"Id":398023,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"31722068725"},{"Id":398024,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"31722069031"},{"Id":398025,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"31722070005"},{"Id":398026,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"31722070010"},{"Id":398027,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"31722070090"},{"Id":398028,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"31722070110"},{"Id":398029,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"31722070130"},{"Id":398030,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"31722070190"},{"Id":398031,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"31722070210"},{"Id":398032,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"31722070230"},{"Id":398033,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"31722070290"},{"Id":398034,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"31722070430"},{"Id":398035,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"31722070490"},{"Id":398036,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"31722070505"},{"Id":398037,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"31722070530"},{"Id":398038,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"31722070590"},{"Id":398039,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000305","GenericName":"FAMCICLOVIR TAB 125 MG","NDC":"31722070630"},{"Id":398040,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000310","GenericName":"FAMCICLOVIR TAB 250 MG","NDC":"31722070730"},{"Id":398041,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000320","GenericName":"FAMCICLOVIR TAB 500 MG","NDC":"31722070830"},{"Id":398042,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"31722071290"},{"Id":398043,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"31722071310"},{"Id":398044,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"31722071390"},{"Id":398045,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"31722072150"},{"Id":398046,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"31722072250"},{"Id":398047,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"31722072320"},{"Id":398048,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"31722072610"},{"Id":398049,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"31722072630"},{"Id":398050,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"31722072690"},{"Id":398051,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"31722072730"},{"Id":398052,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"31722072790"},{"Id":398053,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"31722072830"},{"Id":398054,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"31722072890"},{"Id":398055,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"31722072930"},{"Id":398056,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"31722072990"},{"Id":398057,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"31722073005"},{"Id":398058,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"31722073030"},{"Id":398059,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"31722073090"},{"Id":398060,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"31722073130"},{"Id":398061,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"31722073190"},{"Id":398062,"FormularyType":"OHP","DrugName":"EFAVIR/EMTRI TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903300320","GenericName":"EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG","NDC":"31722073630"},{"Id":398063,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"31722073705"},{"Id":398064,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"31722073730"},{"Id":398065,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"31722073790"},{"Id":398066,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"31722073805"},{"Id":398067,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"31722073830"},{"Id":398068,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"31722073890"},{"Id":398069,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"31722074530"},{"Id":398070,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"31722074690"},{"Id":398071,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"31722074790"},{"Id":398072,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"31722074890"},{"Id":398073,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"31722074920"},{"Id":398074,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"31722074930"},{"Id":398075,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352050000315","GenericName":"LAMIVUDINE TAB 100 MG (HBV)","NDC":"31722075260"},{"Id":398076,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"31722075360"},{"Id":398077,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000330","GenericName":"LAMIVUDINE TAB 300 MG","NDC":"31722075430"},{"Id":398078,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000110","GenericName":"POMALIDOMIDE CAP 1 MG","NDC":"31722077021"},{"Id":398079,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000115","GenericName":"POMALIDOMIDE CAP 2 MG","NDC":"31722077121"},{"Id":398080,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000120","GenericName":"POMALIDOMIDE CAP 3 MG","NDC":"31722077221"},{"Id":398081,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000125","GenericName":"POMALIDOMIDE CAP 4 MG","NDC":"31722077321"},{"Id":398082,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"31722077460"},{"Id":398083,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"31722077512"},{"Id":398084,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"31722077560"},{"Id":398085,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"31722077605"},{"Id":398086,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"31722077690"},{"Id":398087,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"31722077701"},{"Id":398088,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"31722077705"},{"Id":398089,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"31722077801"},{"Id":398090,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"31722077805"},{"Id":398091,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"31722078033"},{"Id":398092,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"31722078034"},{"Id":398093,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"31722080560"},{"Id":398094,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"31722080605"},{"Id":398095,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"31722080660"},{"Id":398096,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"31722080760"},{"Id":398097,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"31722080860"},{"Id":398098,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"31722081260"},{"Id":398099,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"31722081360"},{"Id":398100,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"31722081460"},{"Id":398101,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"31722081560"},{"Id":398102,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"31722082111"},{"Id":398103,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"31722082211"},{"Id":398104,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"31722083260"},{"Id":398105,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"31722083330"},{"Id":398106,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"31722083390"},{"Id":398107,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"31722083430"},{"Id":398108,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"31722083710"},{"Id":398109,"FormularyType":"OHP","DrugName":"ABACA/LAMIVU TAB 600-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902200340","GenericName":"ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG","NDC":"31722083830"},{"Id":398110,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100310","GenericName":"ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","NDC":"31722084130"},{"Id":398111,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100320","GenericName":"ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","NDC":"31722084230"},{"Id":398112,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100330","GenericName":"ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","NDC":"31722084330"},{"Id":398113,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100340","GenericName":"ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","NDC":"31722084430"},{"Id":398114,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"31722085230"},{"Id":398115,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"31722085290"},{"Id":398116,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"31722085330"},{"Id":398117,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"31722085390"},{"Id":398118,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"31722085430"},{"Id":398119,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"31722085490"},{"Id":398120,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"31722085501"},{"Id":398121,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"31722085530"},{"Id":398122,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"31722085601"},{"Id":398123,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"31722085630"},{"Id":398124,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"31722085701"},{"Id":398125,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"31722085730"},{"Id":398126,"FormularyType":"OHP","DrugName":"LINEZOLID SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040001920","GenericName":"LINEZOLID FOR SUSP 100 MG/5ML","NDC":"31722086525"},{"Id":398127,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"31722086803"},{"Id":398128,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"31722086831"},{"Id":398129,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"31722086903"},{"Id":398130,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"31722087227"},{"Id":398131,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"31722087290"},{"Id":398132,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"31722087390"},{"Id":398133,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"31722087801"},{"Id":398134,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"31722087805"},{"Id":398135,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"31722087901"},{"Id":398136,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"31722087905"},{"Id":398137,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"31722088290"},{"Id":398138,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"31722088390"},{"Id":398139,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"31722088490"},{"Id":398140,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"31722088530"},{"Id":398141,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"31722088630"},{"Id":398142,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"31722088690"},{"Id":398143,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"31722088730"},{"Id":398144,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"31722088790"},{"Id":398145,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"31722088830"},{"Id":398146,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"31722088890"},{"Id":398147,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"31722088930"},{"Id":398148,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"31722089901"},{"Id":398149,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"31722089930"},{"Id":398150,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"31722090105"},{"Id":398151,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"31722090130"},{"Id":398152,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"31722090190"},{"Id":398153,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"31722090990"},{"Id":398154,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"31722091090"},{"Id":398155,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"31722091190"},{"Id":398156,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"31722091701"},{"Id":398157,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"31722091705"},{"Id":398158,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"31722091801"},{"Id":398159,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"31722091805"},{"Id":398160,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"31722093431"},{"Id":398161,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"31722093432"},{"Id":398162,"FormularyType":"OHP","DrugName":"SIMPLE SYRUP SYP NF","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"31722093747"},{"Id":398163,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"31722093847"},{"Id":398164,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"31722094201"},{"Id":398165,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"31722094205"},{"Id":398166,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"31722094432"},{"Id":398167,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"31722094531"},{"Id":398168,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"31722094532"},{"Id":398169,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"31722094901"},{"Id":398170,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"31722094905"},{"Id":398171,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"31722095001"},{"Id":398172,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"31722095005"},{"Id":398173,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"31722095101"},{"Id":398174,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"31722095105"},{"Id":398175,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 18MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100460","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG","NDC":"31722095201"},{"Id":398176,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 27MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100465","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","NDC":"31722095301"},{"Id":398177,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"31722095401"},{"Id":398178,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 54MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100480","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","NDC":"31722095501"},{"Id":398179,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"31722095601"},{"Id":398180,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"31722095605"},{"Id":398181,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"31722095801"},{"Id":398182,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"31722095805"},{"Id":398183,"FormularyType":"OHP","DrugName":"SOSWEET SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"31722095901"},{"Id":398184,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000110","GenericName":"DRONABINOL CAP 2.5 MG","NDC":"31722096060"},{"Id":398185,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000115","GenericName":"DRONABINOL CAP 5 MG","NDC":"31722096160"},{"Id":398186,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000120","GenericName":"DRONABINOL CAP 10 MG","NDC":"31722096260"},{"Id":398187,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"31722097460"},{"Id":398188,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"31722099601"},{"Id":398189,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"31722099605"},{"Id":398190,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"31722099701"},{"Id":398191,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"31722099705"},{"Id":398192,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"31722099801"},{"Id":398193,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"31722099810"},{"Id":398194,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"31722099901"},{"Id":398195,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"31722099905"},{"Id":398196,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"31722099910"},{"Id":398197,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"32671000500"},{"Id":398198,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"32671000501"},{"Id":398199,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"32671000502"},{"Id":398200,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"32671000503"},{"Id":398201,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"32671000504"},{"Id":398202,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"32671000505"},{"Id":398203,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"32671000506"},{"Id":398204,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"32671000507"},{"Id":398205,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"32671000508"},{"Id":398206,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"32671000509"},{"Id":398207,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"32671000510"},{"Id":398208,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"32671000511"},{"Id":398209,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"32671000512"},{"Id":398210,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"32671000513"},{"Id":398211,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"32671000514"},{"Id":398212,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"32671000515"},{"Id":398213,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"32671000516"},{"Id":398214,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"32671000517"},{"Id":398215,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"32671000518"},{"Id":398216,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"32671000519"},{"Id":398217,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"32671000520"},{"Id":398218,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"32671000532"},{"Id":398219,"FormularyType":"OHP","DrugName":"LITETOUCH MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"32671000533"},{"Id":398220,"FormularyType":"OHP","DrugName":"LITETOUCH MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"32671000534"},{"Id":398221,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"32671000535"},{"Id":398222,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"32671010531"},{"Id":398223,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"32671010532"},{"Id":398224,"FormularyType":"OHP","DrugName":"LITETOUCH MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"32671010534"},{"Id":398225,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"32671010535"},{"Id":398226,"FormularyType":"OHP","DrugName":"PIP PEN NEED MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"32671010931"},{"Id":398227,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"32671010932"},{"Id":398228,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"32671020513"},{"Id":398229,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"32671020514"},{"Id":398230,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"32671020515"},{"Id":398231,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"32671020517"},{"Id":398232,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"32671020518"},{"Id":398233,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"32671020519"},{"Id":398234,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"32671020520"},{"Id":398235,"FormularyType":"OHP","DrugName":"VARIBAR SUS NECTAR","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909011600"},{"Id":398236,"FormularyType":"OHP","DrugName":"VARIBAR SUS NECTAR","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909011655"},{"Id":398237,"FormularyType":"OHP","DrugName":"VARIBAR THIN SUS HONEY","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909012107"},{"Id":398238,"FormularyType":"OHP","DrugName":"VARIBAR THIN SUS HONEY","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909012154"},{"Id":398239,"FormularyType":"OHP","DrugName":"VARIBAR HONE SUS 40%","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909012207"},{"Id":398240,"FormularyType":"OHP","DrugName":"VARIBAR HONE SUS 40%","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909012254"},{"Id":398241,"FormularyType":"OHP","DrugName":"TAGITOL V SUS 40%","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"RADIOGRAPHIC CONTRAST MEDIA","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94401010101834","GenericName":"BARIUM SULFATE SUSP 40%","NDC":"32909081455"},{"Id":398242,"FormularyType":"OHP","DrugName":"AFLURIA INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"33332002503"},{"Id":398243,"FormularyType":"OHP","DrugName":"AFLURIA INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"33332002504"},{"Id":398244,"FormularyType":"OHP","DrugName":"AFLURIA INJ 2025-26","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020201800","GenericName":"INFLUENZA VIRUS VACCINE SPLIT IM SUSP","NDC":"33332012510"},{"Id":398245,"FormularyType":"OHP","DrugName":"AFLURIA INJ 2025-26","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020201800","GenericName":"INFLUENZA VIRUS VACCINE SPLIT IM SUSP","NDC":"33332012511"},{"Id":398246,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"33342000109"},{"Id":398247,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000330","GenericName":"LAMIVUDINE TAB 300 MG","NDC":"33342000207"},{"Id":398248,"FormularyType":"OHP","DrugName":"LAMIVUD/ZIDO TAB 150-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902500320","GenericName":"LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG","NDC":"33342000309"},{"Id":398249,"FormularyType":"OHP","DrugName":"NEVIRAPINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050000320","GenericName":"NEVIRAPINE TAB 200 MG","NDC":"33342000409"},{"Id":398250,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000305","GenericName":"FAMCICLOVIR TAB 125 MG","NDC":"33342002407"},{"Id":398251,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000310","GenericName":"FAMCICLOVIR TAB 250 MG","NDC":"33342002507"},{"Id":398252,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000320","GenericName":"FAMCICLOVIR TAB 500 MG","NDC":"33342002607"},{"Id":398253,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"33342002707"},{"Id":398254,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"33342002710"},{"Id":398255,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"33342002715"},{"Id":398256,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"33342002807"},{"Id":398257,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"33342002810"},{"Id":398258,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"33342002815"},{"Id":398259,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025107210","GenericName":"DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG","NDC":"33342002907"},{"Id":398260,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025107220","GenericName":"DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG","NDC":"33342003007"},{"Id":398261,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"33342004407"},{"Id":398262,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"33342004410"},{"Id":398263,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"33342004444"},{"Id":398264,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"33342004507"},{"Id":398265,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"33342004510"},{"Id":398266,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"33342004544"},{"Id":398267,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"33342004607"},{"Id":398268,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"33342004610"},{"Id":398269,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"33342004644"},{"Id":398270,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"33342004707"},{"Id":398271,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"33342004710"},{"Id":398272,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"33342004807"},{"Id":398273,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"33342004810"},{"Id":398274,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"33342004907"},{"Id":398275,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"33342004910"},{"Id":398276,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"33342005007"},{"Id":398277,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"33342005010"},{"Id":398278,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"33342005044"},{"Id":398279,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"33342005107"},{"Id":398280,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"33342005110"},{"Id":398281,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"33342005144"},{"Id":398282,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"33342005207"},{"Id":398283,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"33342005210"},{"Id":398284,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"33342005244"},{"Id":398285,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"33342005407"},{"Id":398286,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"33342005410"},{"Id":398287,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"33342005415"},{"Id":398288,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"33342005507"},{"Id":398289,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"33342005510"},{"Id":398290,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"33342005515"},{"Id":398291,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"33342005607"},{"Id":398292,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"33342005610"},{"Id":398293,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"33342005615"},{"Id":398294,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"33342005707"},{"Id":398295,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"33342005710"},{"Id":398296,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"33342005807"},{"Id":398297,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"33342005810"},{"Id":398298,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"33342006007"},{"Id":398299,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"33342006010"},{"Id":398300,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"33342006015"},{"Id":398301,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"33342006207"},{"Id":398302,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"33342006310"},{"Id":398303,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"33342006410"},{"Id":398304,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"33342006510"},{"Id":398305,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"33342007410"},{"Id":398306,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"33342007510"},{"Id":398307,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"33342007515"},{"Id":398308,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"33342007610"},{"Id":398309,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"33342007615"},{"Id":398310,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"33342007710"},{"Id":398311,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"33342007715"},{"Id":398312,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"33342007810"},{"Id":398313,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"33342007815"},{"Id":398314,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"33342008741"},{"Id":398315,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"33342008745"},{"Id":398316,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"33342008841"},{"Id":398317,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"33342008845"},{"Id":398318,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"33342008909"},{"Id":398319,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"33342008915"},{"Id":398320,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"33342009009"},{"Id":398321,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"33342009015"},{"Id":398322,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"33342009109"},{"Id":398323,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"33342009115"},{"Id":398324,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"33342009209"},{"Id":398325,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"33342009215"},{"Id":398326,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"33342009302"},{"Id":398327,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"33342009341"},{"Id":398328,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"33342009345"},{"Id":398329,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"33342009352"},{"Id":398330,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"33342009372"},{"Id":398331,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"33342009373"},{"Id":398332,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"33342009402"},{"Id":398333,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"33342009441"},{"Id":398334,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"33342009445"},{"Id":398335,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"33342009452"},{"Id":398336,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"33342009472"},{"Id":398337,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"33342009473"},{"Id":398338,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"33342009607"},{"Id":398339,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"33342009709"},{"Id":398340,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"33342009715"},{"Id":398341,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"33342009809"},{"Id":398342,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"33342009815"},{"Id":398343,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"33342010207"},{"Id":398344,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"33342010210"},{"Id":398345,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"33342010215"},{"Id":398346,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"33342010607"},{"Id":398347,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100305","GenericName":"RISEDRONATE SODIUM TAB 5 MG","NDC":"33342010707"},{"Id":398348,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"33342010937"},{"Id":398349,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"33342010950"},{"Id":398350,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"33342011007"},{"Id":398351,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"33342011010"},{"Id":398352,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"33342011107"},{"Id":398353,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"33342011110"},{"Id":398354,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100310","GenericName":"CANDESARTAN CILEXETIL TAB 4 MG","NDC":"33342011407"},{"Id":398355,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100310","GenericName":"CANDESARTAN CILEXETIL TAB 4 MG","NDC":"33342011410"},{"Id":398356,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"33342011507"},{"Id":398357,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"33342011510"},{"Id":398358,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"33342011607"},{"Id":398359,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"33342011610"},{"Id":398360,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"33342011707"},{"Id":398361,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"33342011710"},{"Id":398362,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"33342012110"},{"Id":398363,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 16-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200320","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG","NDC":"33342013110"},{"Id":398364,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 16-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200320","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG","NDC":"33342013115"},{"Id":398365,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200340","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG","NDC":"33342013210"},{"Id":398366,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200340","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG","NDC":"33342013215"},{"Id":398367,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200350","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-25 MG","NDC":"33342013310"},{"Id":398368,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200350","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-25 MG","NDC":"33342013315"},{"Id":398369,"FormularyType":"OHP","DrugName":"EFAVIR/EMTRI TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903300320","GenericName":"EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG","NDC":"33342013807"},{"Id":398370,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"33342015052"},{"Id":398371,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"33342015611"},{"Id":398372,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"33342015615"},{"Id":398373,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"33342015711"},{"Id":398374,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"33342015715"},{"Id":398375,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"33342015911"},{"Id":398376,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"33342015915"},{"Id":398377,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"33342015944"},{"Id":398378,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"33342017307"},{"Id":398379,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"33342017310"},{"Id":398380,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"33342017407"},{"Id":398381,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"33342017410"},{"Id":398382,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"33342017507"},{"Id":398383,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"33342017510"},{"Id":398384,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400320","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","NDC":"33342017609"},{"Id":398385,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400320","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","NDC":"33342017657"},{"Id":398386,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-850MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400340","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","NDC":"33342017709"},{"Id":398387,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-850MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400340","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","NDC":"33342017757"},{"Id":398388,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"33342017807"},{"Id":398389,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"33342017907"},{"Id":398390,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"33342017910"},{"Id":398391,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"33342018007"},{"Id":398392,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"33342018010"},{"Id":398393,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG ER","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"33342018710"},{"Id":398394,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"33342018910"},{"Id":398395,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"33342021558"},{"Id":398396,"FormularyType":"OHP","DrugName":"NEVIRAPINE TAB 400MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050007520","GenericName":"NEVIRAPINE TAB ER 24HR 400 MG","NDC":"33342023807"},{"Id":398397,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"33342023911"},{"Id":398398,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"33342024011"},{"Id":398399,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100320","GenericName":"SEVELAMER HCL TAB 400 MG","NDC":"33342024165"},{"Id":398400,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100340","GenericName":"SEVELAMER HCL TAB 800 MG","NDC":"33342024257"},{"Id":398401,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"33342025666"},{"Id":398402,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"33342025766"},{"Id":398403,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"33342025866"},{"Id":398404,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"33342026011"},{"Id":398405,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"33342027407"},{"Id":398406,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"33342027507"},{"Id":398407,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"33342027809"},{"Id":398408,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"33342028868"},{"Id":398409,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"33342028968"},{"Id":398410,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"33342029370"},{"Id":398411,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"33342029371"},{"Id":398412,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"33342029709"},{"Id":398413,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"33342029715"},{"Id":398414,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"33342029809"},{"Id":398415,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"33342029815"},{"Id":398416,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"33342029907"},{"Id":398417,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"33342030011"},{"Id":398418,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"33342030111"},{"Id":398419,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"33342030209"},{"Id":398420,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"33342030309"},{"Id":398421,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"33342030409"},{"Id":398422,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"33342030509"},{"Id":398423,"FormularyType":"OHP","DrugName":"PROPYLTHIOUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300020000310","GenericName":"PROPYLTHIOURACIL TAB 50 MG","NDC":"33342031411"},{"Id":398424,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"33342032084"},{"Id":398425,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"33342032085"},{"Id":398426,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"33342032186"},{"Id":398427,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"33342032715"},{"Id":398428,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"33342032780"},{"Id":398429,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103720","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.5%","NDC":"33342032815"},{"Id":398430,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"33342032915"},{"Id":398431,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"33342032954"},{"Id":398432,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"33342032980"},{"Id":398433,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"33342033115"},{"Id":398434,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"33342033154"},{"Id":398435,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"33342033180"},{"Id":398436,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.5%","DosageForm":"OINT - Ointment","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104215","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.5%","NDC":"33342033215"},{"Id":398437,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"33342033315"},{"Id":398438,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"33342033354"},{"Id":398439,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"33342033380"},{"Id":398440,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"33342033511"},{"Id":398441,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"33342033611"},{"Id":398442,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"33342034994"},{"Id":398443,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"33342035009"},{"Id":398444,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"33342039310"},{"Id":398445,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"33342039311"},{"Id":398446,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"33342039344"},{"Id":398447,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"33342039410"},{"Id":398448,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"33342039411"},{"Id":398449,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"33342039444"},{"Id":398450,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"33342039510"},{"Id":398451,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"33342039511"},{"Id":398452,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"33342039544"},{"Id":398453,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"33342039610"},{"Id":398454,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"33342039611"},{"Id":398455,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"33342039644"},{"Id":398456,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"33342039710"},{"Id":398457,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"33342039711"},{"Id":398458,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"33342039744"},{"Id":398459,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"33342039810"},{"Id":398460,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"33342039811"},{"Id":398461,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"33342039844"},{"Id":398462,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"33342039910"},{"Id":398463,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"33342039911"},{"Id":398464,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"33342039944"},{"Id":398465,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"33342040010"},{"Id":398466,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"33342040011"},{"Id":398467,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"33342040044"},{"Id":398468,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"33342040110"},{"Id":398469,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"33342040111"},{"Id":398470,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"33342040144"},{"Id":398471,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"33342040210"},{"Id":398472,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"33342040211"},{"Id":398473,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"33342040244"},{"Id":398474,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"33342040310"},{"Id":398475,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"33342040311"},{"Id":398476,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"33342040344"},{"Id":398477,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"33342040410"},{"Id":398478,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"33342040411"},{"Id":398479,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"33342040444"},{"Id":398480,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"33342044711"},{"Id":398481,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"33342044715"},{"Id":398482,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"33342046915"},{"Id":398483,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"33342046930"},{"Id":398484,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000U","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"33342048115"},{"Id":398485,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000U","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"33342048130"},{"Id":398486,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"33342048215"},{"Id":398487,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"33342048230"},{"Id":398488,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"33342048260"},{"Id":398489,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"33342048315"},{"Id":398490,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"33342048330"},{"Id":398491,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"33342048360"},{"Id":398492,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"33342048919"},{"Id":398493,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"33342049019"},{"Id":398494,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"33342050615"},{"Id":398495,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"33342050630"},{"Id":398496,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"33342050645"},{"Id":398497,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"33342050660"},{"Id":398498,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"33342053108"},{"Id":398499,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"33342053208"},{"Id":398500,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"33342053332"},{"Id":398501,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"33342053610"},{"Id":398502,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"33342055409"},{"Id":398503,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"33342057009"},{"Id":398504,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"33342057057"},{"Id":398505,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"33342057109"},{"Id":398506,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"33342057157"},{"Id":398507,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"33342057209"},{"Id":398508,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"33342057257"},{"Id":398509,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"33342057749"},{"Id":398510,"FormularyType":"OHP","DrugName":"ALIVE PRENAT CHW DAILY SU","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000524","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.18-25 MG***","NDC":"33674010488"},{"Id":398511,"FormularyType":"OHP","DrugName":"ALIVE PREM CAP PRENATAL","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000105","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 13.5-0.2-100 MG***","NDC":"33674011209"},{"Id":398512,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"33674013608"},{"Id":398513,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"33674013750"},{"Id":398514,"FormularyType":"OHP","DrugName":"BRAIN BUILD CHW KIDS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"33674013882"},{"Id":398515,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"33674015590"},{"Id":398516,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"33674015836"},{"Id":398517,"FormularyType":"OHP","DrugName":"VITAMIN D-3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"33739000373"},{"Id":398518,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"33739000377"},{"Id":398519,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 3MG/0.9","DosageForm":"LIQD - Liquid","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000949","GenericName":"MELATONIN LIQUID 3 MG/0.9ML","NDC":"33739003261"},{"Id":398520,"FormularyType":"OHP","DrugName":"DENOREX EXTR SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"35379032046"},{"Id":398521,"FormularyType":"OHP","DrugName":"POLYMEM DOT PAD 2\" X 2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"35471010203"},{"Id":398522,"FormularyType":"OHP","DrugName":"POLYMEM DOT PAD 2\" X 2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"35471020203"},{"Id":398523,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515068527"},{"Id":398524,"FormularyType":"OHP","DrugName":"QC SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"35515090000"},{"Id":398525,"FormularyType":"OHP","DrugName":"QC FIBER TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"35515090023"},{"Id":398526,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"35515090057"},{"Id":398527,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"35515090111"},{"Id":398528,"FormularyType":"OHP","DrugName":"CALC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"35515090120"},{"Id":398529,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"35515090121"},{"Id":398530,"FormularyType":"OHP","DrugName":"QC ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"35515090123"},{"Id":398531,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"35515090124"},{"Id":398532,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"35515090128"},{"Id":398533,"FormularyType":"OHP","DrugName":"COMP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"35515090180"},{"Id":398534,"FormularyType":"OHP","DrugName":"QC CHILDRENS CHW EXTRA C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"35515090321"},{"Id":398535,"FormularyType":"OHP","DrugName":"QC VIT B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"35515090326"},{"Id":398536,"FormularyType":"OHP","DrugName":"QC NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000310","GenericName":"NIACINAMIDE TAB 100 MG","NDC":"35515090327"},{"Id":398537,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"35515090330"},{"Id":398538,"FormularyType":"OHP","DrugName":"QC ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"35515090380"},{"Id":398539,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"35515090431"},{"Id":398540,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"35515090432"},{"Id":398541,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515090542"},{"Id":398542,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515090840"},{"Id":398543,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515090842"},{"Id":398544,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515090843"},{"Id":398545,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"35515090856"},{"Id":398546,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515090857"},{"Id":398547,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515090893"},{"Id":398548,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515090894"},{"Id":398549,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"35515091122"},{"Id":398550,"FormularyType":"OHP","DrugName":"QC IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"35515093515"},{"Id":398551,"FormularyType":"OHP","DrugName":"STERILE PADS PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"35515094420"},{"Id":398552,"FormularyType":"OHP","DrugName":"QC GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"35515094560"},{"Id":398553,"FormularyType":"OHP","DrugName":"COMP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"35515094576"},{"Id":398554,"FormularyType":"OHP","DrugName":"COMP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"35515094577"},{"Id":398555,"FormularyType":"OHP","DrugName":"COMP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"35515094579"},{"Id":398556,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"35515094594"},{"Id":398557,"FormularyType":"OHP","DrugName":"QC HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"35515094613"},{"Id":398558,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"35515094634"},{"Id":398559,"FormularyType":"OHP","DrugName":"QC FIBER POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"35515094675"},{"Id":398560,"FormularyType":"OHP","DrugName":"QC NATURAL POW VEGETABL","DosageForm":"POWD - Powder","Strength":"95","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102995","GenericName":"PSYLLIUM POWDER 95%","NDC":"35515094676"},{"Id":398561,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"35515094753"},{"Id":398562,"FormularyType":"OHP","DrugName":"QC PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"35515094774"},{"Id":398563,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"35515094808"},{"Id":398564,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"35515094810"},{"Id":398565,"FormularyType":"OHP","DrugName":"QC ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"35515095104"},{"Id":398566,"FormularyType":"OHP","DrugName":"QC FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"35515095118"},{"Id":398567,"FormularyType":"OHP","DrugName":"QC APAP 8 HR TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"35515095198"},{"Id":398568,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"35515095225"},{"Id":398569,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"35515095226"},{"Id":398570,"FormularyType":"OHP","DrugName":"QC ALCOHOL MIS WIPE 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"35515095228"},{"Id":398571,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515095233"},{"Id":398572,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"35515095290"},{"Id":398573,"FormularyType":"OHP","DrugName":"BORDER GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"35515095293"},{"Id":398574,"FormularyType":"OHP","DrugName":"REST SIMPLY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"35515095330"},{"Id":398575,"FormularyType":"OHP","DrugName":"CHLOR-PHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"35515095357"},{"Id":398576,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"35515095360"},{"Id":398577,"FormularyType":"OHP","DrugName":"FIBER LAXTIV CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"35515095372"},{"Id":398578,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"35515095386"},{"Id":398579,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"35515095400"},{"Id":398580,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"35515095423"},{"Id":398581,"FormularyType":"OHP","DrugName":"QC LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"35515095451"},{"Id":398582,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"35515095479"},{"Id":398583,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"35515095498"},{"Id":398584,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"35515095526"},{"Id":398585,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"35515095563"},{"Id":398586,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515095609"},{"Id":398587,"FormularyType":"OHP","DrugName":"QC SLEEP AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"35515095673"},{"Id":398588,"FormularyType":"OHP","DrugName":"QC VIT D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"35515095723"},{"Id":398589,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515095771"},{"Id":398590,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"35515095777"},{"Id":398591,"FormularyType":"OHP","DrugName":"QC SUPHEDRIN TAB 120MG SR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"35515095785"},{"Id":398592,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 1MG/ML","DosageForm":"SYRP - Syrup","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"35515095797"},{"Id":398593,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"35515095798"},{"Id":398594,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"35515095799"},{"Id":398595,"FormularyType":"OHP","DrugName":"QC APAP 8 HR TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"35515095859"},{"Id":398596,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"35515095891"},{"Id":398597,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"35515095898"},{"Id":398598,"FormularyType":"OHP","DrugName":"QC VIT B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"35515095912"},{"Id":398599,"FormularyType":"OHP","DrugName":"QC VIT B6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"35515095913"},{"Id":398600,"FormularyType":"OHP","DrugName":"CALC/MAGNESM TAB ZINC/D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450320","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 333.4 MG-133 UNT***","NDC":"35515095914"},{"Id":398601,"FormularyType":"OHP","DrugName":"QC VIT D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"35515095917"},{"Id":398602,"FormularyType":"OHP","DrugName":"QC MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"35515095982"},{"Id":398603,"FormularyType":"OHP","DrugName":"QC FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"35515095983"},{"Id":398604,"FormularyType":"OHP","DrugName":"REST SIMPLY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"35515095997"},{"Id":398605,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515096510"},{"Id":398606,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"35515096524"},{"Id":398607,"FormularyType":"OHP","DrugName":"QC VIT B12 TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"35515096591"},{"Id":398608,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"35515096602"},{"Id":398609,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"35515096615"},{"Id":398610,"FormularyType":"OHP","DrugName":"QC VIT D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"35515096680"},{"Id":398611,"FormularyType":"OHP","DrugName":"QC VIT D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"35515096685"},{"Id":398612,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"35515096706"},{"Id":398613,"FormularyType":"OHP","DrugName":"TRAVEL EASE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"35515096707"},{"Id":398614,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515096748"},{"Id":398615,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515096749"},{"Id":398616,"FormularyType":"OHP","DrugName":"QC ACETAMINO SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"35515096815"},{"Id":398617,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"35515096837"},{"Id":398618,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"35515096848"},{"Id":398619,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"35515096943"},{"Id":398620,"FormularyType":"OHP","DrugName":"QC HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"35515096985"},{"Id":398621,"FormularyType":"OHP","DrugName":"QC ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"35515097004"},{"Id":398622,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"35515097006"},{"Id":398623,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"35515097059"},{"Id":398624,"FormularyType":"OHP","DrugName":"NIGHT TIME TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"35515097988"},{"Id":398625,"FormularyType":"OHP","DrugName":"QC POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"35515098037"},{"Id":398626,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"35515098043"},{"Id":398627,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515098074"},{"Id":398628,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515098075"},{"Id":398629,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515098076"},{"Id":398630,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515098077"},{"Id":398631,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"35515098131"},{"Id":398632,"FormularyType":"OHP","DrugName":"CHLOR-PHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"35515098227"},{"Id":398633,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"35515098304"},{"Id":398634,"FormularyType":"OHP","DrugName":"WOMANS LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"35515098305"},{"Id":398635,"FormularyType":"OHP","DrugName":"QC ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"35515098306"},{"Id":398636,"FormularyType":"OHP","DrugName":"QC LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"35515098369"},{"Id":398637,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"35515098528"},{"Id":398638,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"35515098637"},{"Id":398639,"FormularyType":"OHP","DrugName":"QC VIT D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"35515098641"},{"Id":398640,"FormularyType":"OHP","DrugName":"QC VIT D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"35515098642"},{"Id":398641,"FormularyType":"OHP","DrugName":"QC VIT D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"35515098643"},{"Id":398642,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"35515098722"},{"Id":398643,"FormularyType":"OHP","DrugName":"QC LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"35515098841"},{"Id":398644,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"35515098842"},{"Id":398645,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"35515098866"},{"Id":398646,"FormularyType":"OHP","DrugName":"QC TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"35515099196"},{"Id":398647,"FormularyType":"OHP","DrugName":"QC ZINC OXID OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"35515099197"},{"Id":398648,"FormularyType":"OHP","DrugName":"QC T+PLUS SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"35515099256"},{"Id":398649,"FormularyType":"OHP","DrugName":"QC TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"35515099258"},{"Id":398650,"FormularyType":"OHP","DrugName":"QC ANTI-ITCH CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"35515099259"},{"Id":398651,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"35515099260"},{"Id":398652,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"35515099261"},{"Id":398653,"FormularyType":"OHP","DrugName":"QC MENSTRUAL TAB COMPLETE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"35515099321"},{"Id":398654,"FormularyType":"OHP","DrugName":"MOTION SICK TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"35515099327"},{"Id":398655,"FormularyType":"OHP","DrugName":"QC CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450350","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-400 UNIT***","NDC":"35515099541"},{"Id":398656,"FormularyType":"OHP","DrugName":"PSEUDOFED TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"35515099569"},{"Id":398657,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"35515099602"},{"Id":398658,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"35515099614"},{"Id":398659,"FormularyType":"OHP","DrugName":"ESOMEPRAZOLE CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"35515099635"},{"Id":398660,"FormularyType":"OHP","DrugName":"ESOMEPRAZOLE CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"35515099636"},{"Id":398661,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"35515099637"},{"Id":398662,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"35515099677"},{"Id":398663,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"35515099682"},{"Id":398664,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"35515099683"},{"Id":398665,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"35515099684"},{"Id":398666,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"35515099685"},{"Id":398667,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"35515099686"},{"Id":398668,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"35515099687"},{"Id":398669,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"35515099716"},{"Id":398670,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515099721"},{"Id":398671,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"35515099734"},{"Id":398672,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"35515099735"},{"Id":398673,"FormularyType":"OHP","DrugName":"QC LORATADIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"35515099736"},{"Id":398674,"FormularyType":"OHP","DrugName":"QC DICLOFENA GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"35515099803"},{"Id":398675,"FormularyType":"OHP","DrugName":"QC NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"35515099805"},{"Id":398676,"FormularyType":"OHP","DrugName":"QC NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"35515099806"},{"Id":398677,"FormularyType":"OHP","DrugName":"QC MELATONIN TAB 10MG","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000440","GenericName":"MELATONIN TAB ER 10 MG","NDC":"35515099820"},{"Id":398678,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"35515099822"},{"Id":398679,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"35515099823"},{"Id":398680,"FormularyType":"OHP","DrugName":"QC ACETAMINO SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"35515099852"},{"Id":398681,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"35515099856"},{"Id":398682,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"35515099885"},{"Id":398683,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN MULTI 1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"35515099888"},{"Id":398684,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"35515099904"},{"Id":398685,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"35515099919"},{"Id":398686,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"35515099928"},{"Id":398687,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"35515099938"},{"Id":398688,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"35515099943"},{"Id":398689,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"35515099976"},{"Id":398690,"FormularyType":"OHP","DrugName":"QC T+PLUS SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"35515099982"},{"Id":398691,"FormularyType":"OHP","DrugName":"QC ALCOHOL PAD SWABS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"35515099989"},{"Id":398692,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"35561021112"},{"Id":398693,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"35561021113"},{"Id":398694,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"35561028510"},{"Id":398695,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"35561028511"},{"Id":398696,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"35561028610"},{"Id":398697,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"35561028611"},{"Id":398698,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"35561034311"},{"Id":398699,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"35561034411"},{"Id":398700,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"35561034413"},{"Id":398701,"FormularyType":"OHP","DrugName":"SOD POLY SUL SUS 15GM/60","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001805","GenericName":"SODIUM POLYSTYRENE SULFONATE SUSP 15 GM/60ML","NDC":"35573010813"},{"Id":398702,"FormularyType":"OHP","DrugName":"SOD POLY SUL SUS 15GM/60","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001805","GenericName":"SODIUM POLYSTYRENE SULFONATE SUSP 15 GM/60ML","NDC":"35573010814"},{"Id":398703,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"35573040099"},{"Id":398704,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"35573042851"},{"Id":398705,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"35573042880"},{"Id":398706,"FormularyType":"OHP","DrugName":"KETOCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11404040000310","GenericName":"KETOCONAZOLE TAB 200 MG","NDC":"35573043302"},{"Id":398707,"FormularyType":"OHP","DrugName":"KETOCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11404040000310","GenericName":"KETOCONAZOLE TAB 200 MG","NDC":"35573043330"},{"Id":398708,"FormularyType":"OHP","DrugName":"SODIUM FLUOR GEL 1.1%","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"35573043556"},{"Id":398709,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"35573044730"},{"Id":398710,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"35573044830"},{"Id":398711,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"35573045308"},{"Id":398712,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"35573045391"},{"Id":398713,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 10% WASH","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"35573045408"},{"Id":398714,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 10% WASH","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"35573045491"},{"Id":398715,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"35573046402"},{"Id":398716,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"35573046502"},{"Id":398717,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"35573046602"},{"Id":398718,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"35573046702"},{"Id":398719,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"35573046802"},{"Id":398720,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"35573046902"},{"Id":398721,"FormularyType":"OHP","DrugName":"NORM-JECT MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"35873001457"},{"Id":398722,"FormularyType":"OHP","DrugName":"NORM-JECT MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"35873001874"},{"Id":398723,"FormularyType":"OHP","DrugName":"NORM-JECT MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"35873001908"},{"Id":398724,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 1.2/30ML","DosageForm":"SOLN - Solution","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102038","GenericName":"TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","NDC":"36000024201"},{"Id":398725,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"36000024401"},{"Id":398726,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"36000024425"},{"Id":398727,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"36000028225"},{"Id":398728,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"36000028325"},{"Id":398729,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"36000028425"},{"Id":398730,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"36000030801"},{"Id":398731,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"36000030810"},{"Id":398732,"FormularyType":"OHP","DrugName":"ALLBEE PLUS TAB VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"36652067366"},{"Id":398733,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"36800000110"},{"Id":398734,"FormularyType":"OHP","DrugName":"ENEMA ENE SINGLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"36800000202"},{"Id":398735,"FormularyType":"OHP","DrugName":"ENEMA ENE SINGLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"36800000236"},{"Id":398736,"FormularyType":"OHP","DrugName":"ENEMA ENE SINGLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"36800002713"},{"Id":398737,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800002925"},{"Id":398738,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"36800003414"},{"Id":398739,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"36800003436"},{"Id":398740,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"36800003449"},{"Id":398741,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800003510"},{"Id":398742,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"36800004413"},{"Id":398743,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"36800005027"},{"Id":398744,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"36800005034"},{"Id":398745,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"36800005058"},{"Id":398746,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"36800005060"},{"Id":398747,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"36800005444"},{"Id":398748,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"36800005452"},{"Id":398749,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"36800005460"},{"Id":398750,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"36800005705"},{"Id":398751,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"36800005748"},{"Id":398752,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"36800006097"},{"Id":398753,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"36800006200"},{"Id":398754,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"36800006687"},{"Id":398755,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"36800008100"},{"Id":398756,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"36800008271"},{"Id":398757,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"36800008336"},{"Id":398758,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800008338"},{"Id":398759,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800008342"},{"Id":398760,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"36800008401"},{"Id":398761,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"36800008902"},{"Id":398762,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"36800009110"},{"Id":398763,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"36800009208"},{"Id":398764,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"36800009234"},{"Id":398765,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800010325"},{"Id":398766,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"36800010326"},{"Id":398767,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800010327"},{"Id":398768,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"36800010335"},{"Id":398769,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"36800011223"},{"Id":398770,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"36800011892"},{"Id":398771,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"36800011893"},{"Id":398772,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800012721"},{"Id":398773,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800012885"},{"Id":398774,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800012888"},{"Id":398775,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800012892"},{"Id":398776,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800012904"},{"Id":398777,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"36800013108"},{"Id":398778,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800013309"},{"Id":398779,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"36800013440"},{"Id":398780,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"36800013444"},{"Id":398781,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"36800014165"},{"Id":398782,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"36800014172"},{"Id":398783,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800014418"},{"Id":398784,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800014516"},{"Id":398785,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800014524"},{"Id":398786,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800014746"},{"Id":398787,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800014747"},{"Id":398788,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"36800014780"},{"Id":398789,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"36800014785"},{"Id":398790,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"36800015068"},{"Id":398791,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800015069"},{"Id":398792,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"36800015712"},{"Id":398793,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"36800016028"},{"Id":398794,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"36800016046"},{"Id":398795,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"36800016626"},{"Id":398796,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"36800017025"},{"Id":398797,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"36800018926"},{"Id":398798,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"36800019234"},{"Id":398799,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"36800019402"},{"Id":398800,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"36800019471"},{"Id":398801,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"36800019975"},{"Id":398802,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"36800019978"},{"Id":398803,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"36800019979"},{"Id":398804,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800020226"},{"Id":398805,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800020625"},{"Id":398806,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"36800022087"},{"Id":398807,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800024419"},{"Id":398808,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800024420"},{"Id":398809,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800024421"},{"Id":398810,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"36800024712"},{"Id":398811,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800024829"},{"Id":398812,"FormularyType":"OHP","DrugName":"NUTR SUPPLE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800025101"},{"Id":398813,"FormularyType":"OHP","DrugName":"NUTR SUPPLE LIQ PLUS VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800025102"},{"Id":398814,"FormularyType":"OHP","DrugName":"NUTR SUPPLE LIQ PL CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800025103"},{"Id":398815,"FormularyType":"OHP","DrugName":"NUTR SUPPLE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800025126"},{"Id":398816,"FormularyType":"OHP","DrugName":"NUTR SUPPLE LIQ STRBERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800025127"},{"Id":398817,"FormularyType":"OHP","DrugName":"NUTR SUPPLE LIQ PL STBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800025128"},{"Id":398818,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"36800025510"},{"Id":398819,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"36800027468"},{"Id":398820,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800030103"},{"Id":398821,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"36800030602"},{"Id":398822,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"36800030603"},{"Id":398823,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"36800030609"},{"Id":398824,"FormularyType":"OHP","DrugName":"ENEMA ENE SINGLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"36800031151"},{"Id":398825,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800032725"},{"Id":398826,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800032726"},{"Id":398827,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"36800033243"},{"Id":398828,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"36800033963"},{"Id":398829,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"36800033964"},{"Id":398830,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"36800033973"},{"Id":398831,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"36800033981"},{"Id":398832,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"36800034403"},{"Id":398833,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"36800034405"},{"Id":398834,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800034650"},{"Id":398835,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800034651"},{"Id":398836,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 160MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010007220","GenericName":"ACETAMINOPHEN DISINTEGRATING TAB 160 MG","NDC":"36800036088"},{"Id":398837,"FormularyType":"OHP","DrugName":"APAP RAPID TAB TAB 80MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010007210","GenericName":"ACETAMINOPHEN DISINTEGRATING TAB 80 MG","NDC":"36800036089"},{"Id":398838,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"36800036347"},{"Id":398839,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"36800036757"},{"Id":398840,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"36800037012"},{"Id":398841,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"36800037545"},{"Id":398842,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800037549"},{"Id":398843,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"36800037554"},{"Id":398844,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"36800037555"},{"Id":398845,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"36800037926"},{"Id":398846,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"36800037934"},{"Id":398847,"FormularyType":"OHP","DrugName":"MICONAZORB POW AF 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"36800038525"},{"Id":398848,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"36800038947"},{"Id":398849,"FormularyType":"OHP","DrugName":"ALL-DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"36800039735"},{"Id":398850,"FormularyType":"OHP","DrugName":"PAIN RELIEF CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000115","GenericName":"ACETAMINOPHEN CAP 500 MG","NDC":"36800041425"},{"Id":398851,"FormularyType":"OHP","DrugName":"ALLRGY RELF TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"36800041435"},{"Id":398852,"FormularyType":"OHP","DrugName":"PAIN RELIEF CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000115","GenericName":"ACETAMINOPHEN CAP 500 MG","NDC":"36800042324"},{"Id":398853,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"36800043162"},{"Id":398854,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"36800043167"},{"Id":398855,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"36800043262"},{"Id":398856,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"36800043267"},{"Id":398857,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"36800044164"},{"Id":398858,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"36800044579"},{"Id":398859,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"36800044983"},{"Id":398860,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800045660"},{"Id":398861,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"36800045678"},{"Id":398862,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800045839"},{"Id":398863,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800045847"},{"Id":398864,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800045866"},{"Id":398865,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800045887"},{"Id":398866,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"36800045895"},{"Id":398867,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"36800046768"},{"Id":398868,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"36800046882"},{"Id":398869,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"36800047207"},{"Id":398870,"FormularyType":"OHP","DrugName":"ALL-DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"36800047526"},{"Id":398871,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"36800047848"},{"Id":398872,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800048462"},{"Id":398873,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800048471"},{"Id":398874,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800048478"},{"Id":398875,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"36800048490"},{"Id":398876,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"36800049816"},{"Id":398877,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800051771"},{"Id":398878,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800051778"},{"Id":398879,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"36800052601"},{"Id":398880,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"36800053260"},{"Id":398881,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"36800053278"},{"Id":398882,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"36800053664"},{"Id":398883,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"36800053905"},{"Id":398884,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800055726"},{"Id":398885,"FormularyType":"OHP","DrugName":"ALLRGY RELF TAB 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"36800058544"},{"Id":398886,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800059016"},{"Id":398887,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"36800059912"},{"Id":398888,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"36800060155"},{"Id":398889,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800060462"},{"Id":398890,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800060471"},{"Id":398891,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800060478"},{"Id":398892,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800060485"},{"Id":398893,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800060490"},{"Id":398894,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"36800061246"},{"Id":398895,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"36800061287"},{"Id":398896,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800064762"},{"Id":398897,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800064771"},{"Id":398898,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800064778"},{"Id":398899,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"36800064790"},{"Id":398900,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"36800064912"},{"Id":398901,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"36800068526"},{"Id":398902,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800069926"},{"Id":398903,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"36800070938"},{"Id":398904,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"36800073402"},{"Id":398905,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"36800076616"},{"Id":398906,"FormularyType":"OHP","DrugName":"8 HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"36800077947"},{"Id":398907,"FormularyType":"OHP","DrugName":"LAX/STL SOFT TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"36800078312"},{"Id":398908,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"36800082529"},{"Id":398909,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"36800087305"},{"Id":398910,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"36800089726"},{"Id":398911,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"36800090002"},{"Id":398912,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"36800090901"},{"Id":398913,"FormularyType":"OHP","DrugName":"LAX/STL SOFT TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"36800093860"},{"Id":398914,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"36800095702"},{"Id":398915,"FormularyType":"OHP","DrugName":"METAMUCIL POW 58.6% SF","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"37000011961"},{"Id":398916,"FormularyType":"OHP","DrugName":"METAMUCIL POW 58.6% SF","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"37000033710"},{"Id":398917,"FormularyType":"OHP","DrugName":"CHILDRENS CHW PEPTO","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000504","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG","NDC":"37000049024"},{"Id":398918,"FormularyType":"OHP","DrugName":"METAMUCIL POW 28.3%ORG","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"37000074079"},{"Id":398919,"FormularyType":"OHP","DrugName":"METAMUCIL POW 58.6%ORG","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"37000074083"},{"Id":398920,"FormularyType":"OHP","DrugName":"METAMUCIL POW 58.6%ORG","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"37000074084"},{"Id":398921,"FormularyType":"OHP","DrugName":"METAMUCIL POW 58.6%ORG","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"37000074085"},{"Id":398922,"FormularyType":"OHP","DrugName":"METAMUCIL WAF","DosageForm":"WAFR - Wafer","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030103100","GenericName":"*PSYLLIUM WAFER**","NDC":"37000074091"},{"Id":398923,"FormularyType":"OHP","DrugName":"METAMUCIL WAF","DosageForm":"WAFR - Wafer","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030103100","GenericName":"*PSYLLIUM WAFER**","NDC":"37000074092"},{"Id":398924,"FormularyType":"OHP","DrugName":"METAMUCIL POW 28.3%ORG","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"37000074134"},{"Id":398925,"FormularyType":"OHP","DrugName":"METAMUCIL POW 58.6%","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"37000074136"},{"Id":398926,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB + D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"37205039272"},{"Id":398927,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"37205057378"},{"Id":398928,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"37205057478"},{"Id":398929,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"37205074685"},{"Id":398930,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"37808037926"},{"Id":398931,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"37808060032"},{"Id":398932,"FormularyType":"OHP","DrugName":"PIN-AWAY SUS 144MG/ML","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"38056008002"},{"Id":398933,"FormularyType":"OHP","DrugName":"EQ ENEMA ENE DOUBLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"38206003021"},{"Id":398934,"FormularyType":"OHP","DrugName":"PREVDNT 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"38341033100"},{"Id":398935,"FormularyType":"OHP","DrugName":"PREVDNT 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"38341033101"},{"Id":398936,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"38379013030"},{"Id":398937,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"38379013031"},{"Id":398938,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"38379013080"},{"Id":398939,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"38379013081"},{"Id":398940,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"38379013180"},{"Id":398941,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"38379013181"},{"Id":398942,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"38379033030"},{"Id":398943,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"38379033031"},{"Id":398944,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"38379033080"},{"Id":398945,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"38379033081"},{"Id":398946,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"38379033180"},{"Id":398947,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"38379033181"},{"Id":398948,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"38379053008"},{"Id":398949,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"38379053030"},{"Id":398950,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"38379053031"},{"Id":398951,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"38379053080"},{"Id":398952,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"38379053180"},{"Id":398953,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"38379053181"},{"Id":398954,"FormularyType":"OHP","DrugName":"PREVENT DROP MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"38703857710"},{"Id":398955,"FormularyType":"OHP","DrugName":"PREVENT DROP MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"38703857810"},{"Id":398956,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"38779003701"},{"Id":398957,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"38779003708"},{"Id":398958,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"38779003709"},{"Id":398959,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779028901"},{"Id":398960,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779028908"},{"Id":398961,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779028909"},{"Id":398962,"FormularyType":"OHP","DrugName":"ORA-PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"38779074308"},{"Id":398963,"FormularyType":"OHP","DrugName":"ORA-SWEET SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"38779074408"},{"Id":398964,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"38779077800"},{"Id":398965,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"38779077801"},{"Id":398966,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"38779077803"},{"Id":398967,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"38779077805"},{"Id":398968,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"38779077807"},{"Id":398969,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"38779077808"},{"Id":398970,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"38779094901"},{"Id":398971,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"38779094908"},{"Id":398972,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"38779094909"},{"Id":398973,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"38779121601"},{"Id":398974,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"38779121608"},{"Id":398975,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"38779177901"},{"Id":398976,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"38779177907"},{"Id":398977,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"38779177908"},{"Id":398978,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"38779210203"},{"Id":398979,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"38779210204"},{"Id":398980,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"38779210205"},{"Id":398981,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"38779210207"},{"Id":398982,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"38779210208"},{"Id":398983,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"38779210209"},{"Id":398984,"FormularyType":"OHP","DrugName":"ORA-SWEET SF SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"38779234308"},{"Id":398985,"FormularyType":"OHP","DrugName":"ORA-BLEND SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"38779234808"},{"Id":398986,"FormularyType":"OHP","DrugName":"ORA-BLEND SF SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"38779234908"},{"Id":398987,"FormularyType":"OHP","DrugName":"ORAL SUSPEND LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"38779251001"},{"Id":398988,"FormularyType":"OHP","DrugName":"ORAL SUSPEND LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"38779251008"},{"Id":398989,"FormularyType":"OHP","DrugName":"ORAL SYP FLAVORED","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"38779251101"},{"Id":398990,"FormularyType":"OHP","DrugName":"ORAL SYP FLAVORED","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"38779251108"},{"Id":398991,"FormularyType":"OHP","DrugName":"ORAL MIX SUS SUSPENDI","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"38779251201"},{"Id":398992,"FormularyType":"OHP","DrugName":"ORAL MIX SUS SUSPENDI","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"38779251208"},{"Id":398993,"FormularyType":"OHP","DrugName":"ORAL SYP SF","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"38779259901"},{"Id":398994,"FormularyType":"OHP","DrugName":"ORAL SYP SF","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"38779259908"},{"Id":398995,"FormularyType":"OHP","DrugName":"ORAL MIX SF SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"38779260001"},{"Id":398996,"FormularyType":"OHP","DrugName":"ORAL MIX SF SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"38779260008"},{"Id":398997,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779307401"},{"Id":398998,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779307407"},{"Id":398999,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779307408"},{"Id":399000,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"38779307409"},{"Id":399001,"FormularyType":"OHP","DrugName":"SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126305","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 18 X 1\"","NDC":"38779644701"},{"Id":399002,"FormularyType":"OHP","DrugName":"12ML SYRINGE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040126305","GenericName":"SYRINGE/NEEDLE (DISP) 12 ML 18 X 1\"","NDC":"38779681901"},{"Id":399003,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"38779720601"},{"Id":399004,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"38779790601"},{"Id":399005,"FormularyType":"OHP","DrugName":"BD LUER-LOK MIS SYR 10ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"38779791002"},{"Id":399006,"FormularyType":"OHP","DrugName":"30ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006330","GenericName":"SYRINGE (DISPOSABLE) 30 ML","NDC":"38779971004"},{"Id":399007,"FormularyType":"OHP","DrugName":"PRO-EX ANTIF CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"38891003060"},{"Id":399008,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"38891003083"},{"Id":399009,"FormularyType":"OHP","DrugName":"PHOSPHO-TRIN TAB K500","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"PHOSPHATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79600010020305","GenericName":"POTASSIUM PHOSPHATE MONOBASIC TAB 500 MG","NDC":"39328000810"},{"Id":399010,"FormularyType":"OHP","DrugName":"MX-SOL SUS SUSPEND","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"39328001416"},{"Id":399011,"FormularyType":"OHP","DrugName":"MX-SOL SF SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"39328001516"},{"Id":399012,"FormularyType":"OHP","DrugName":"MX-SOL BLEND SUS SF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"39328001616"},{"Id":399013,"FormularyType":"OHP","DrugName":"MX-SOL SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"39328001716"},{"Id":399014,"FormularyType":"OHP","DrugName":"MX-SOL BLEND SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"39328001816"},{"Id":399015,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"39328001901"},{"Id":399016,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"39328001903"},{"Id":399017,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"39328001907"},{"Id":399018,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"39328002008"},{"Id":399019,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"39328003150"},{"Id":399020,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"39328003199"},{"Id":399021,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"39328003250"},{"Id":399022,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"39328003299"},{"Id":399023,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650/20.3","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"39328003450"},{"Id":399024,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650/20.3","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"39328003499"},{"Id":399025,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107220","GenericName":"HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","NDC":"39328004910"},{"Id":399026,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"39328005010"},{"Id":399027,"FormularyType":"OHP","DrugName":"HYOSCYAMINE SUB 0.125MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100710","GenericName":"HYOSCYAMINE SULFATE SL TAB 0.125 MG","NDC":"39328005110"},{"Id":399028,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.375 ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0.375","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107420","GenericName":"HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","NDC":"39328005210"},{"Id":399029,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"39328005816"},{"Id":399030,"FormularyType":"OHP","DrugName":"PREGABALIN SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057002020","GenericName":"PREGABALIN SOLN 20 MG/ML","NDC":"39328009016"},{"Id":399031,"FormularyType":"OHP","DrugName":"PRENATAL TAB 27-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"39328010610"},{"Id":399032,"FormularyType":"OHP","DrugName":"PHOSPHO-TRIN TAB 250 NEUT","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"PHOSPHATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79600030100320","GenericName":"POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG","NDC":"39328010710"},{"Id":399033,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"39328012005"},{"Id":399034,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"39328012050"},{"Id":399035,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"39328015705"},{"Id":399036,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"39328022015"},{"Id":399037,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"39328022050"},{"Id":399038,"FormularyType":"OHP","DrugName":"CALCIDOL DRO 8000/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030002030","GenericName":"ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML)","NDC":"39328035760"},{"Id":399039,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"39328051130"},{"Id":399040,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"39328051140"},{"Id":399041,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"39328051150"},{"Id":399042,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"39328053010"},{"Id":399043,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"39328053016"},{"Id":399044,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"39328053099"},{"Id":399045,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"39328054416"},{"Id":399046,"FormularyType":"OHP","DrugName":"IRON DROPS DRO 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"39328055750"},{"Id":399047,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"39822046001"},{"Id":399048,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"39822046002"},{"Id":399049,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"39822047001"},{"Id":399050,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"39822047002"},{"Id":399051,"FormularyType":"OHP","DrugName":"FOLIC ACID INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010002005","GenericName":"FOLIC ACID INJ 5 MG/ML","NDC":"39822110001"},{"Id":399052,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"39822552502"},{"Id":399053,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102005","GenericName":"PROMETHAZINE HCL INJ 25 MG/ML","NDC":"39822552503"},{"Id":399054,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"39822555005"},{"Id":399055,"FormularyType":"OHP","DrugName":"PROMETHAZINE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102010","GenericName":"PROMETHAZINE HCL INJ 50 MG/ML","NDC":"39822555006"},{"Id":399056,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"39822620001"},{"Id":399057,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"39822620002"},{"Id":399058,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 40/10ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"39822625001"},{"Id":399059,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"40093010075"},{"Id":399060,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"40093010077"},{"Id":399061,"FormularyType":"OHP","DrugName":"D3 HIGH POT CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"40093010107"},{"Id":399062,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"40093010116"},{"Id":399063,"FormularyType":"OHP","DrugName":"B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"40093010128"},{"Id":399064,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"65","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"40093010134"},{"Id":399065,"FormularyType":"OHP","DrugName":"POTASSIUM GL TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"40093010135"},{"Id":399066,"FormularyType":"OHP","DrugName":"B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"40093010137"},{"Id":399067,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"40093010148"},{"Id":399068,"FormularyType":"OHP","DrugName":"D3 HIGH POTE CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"40093010150"},{"Id":399069,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"40093010164"},{"Id":399070,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"40093010170"},{"Id":399071,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"40093010175"},{"Id":399072,"FormularyType":"OHP","DrugName":"IRON SLOW TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"40093010195"},{"Id":399073,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"40093010197"},{"Id":399074,"FormularyType":"OHP","DrugName":"MELATONIN TAB 12MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007265","GenericName":"MELATONIN TABLET DISINTEGRATING 12 MG","NDC":"40093010210"},{"Id":399075,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"40093010230"},{"Id":399076,"FormularyType":"OHP","DrugName":"VIT D3 HP CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"40093010231"},{"Id":399077,"FormularyType":"OHP","DrugName":"FISH OIL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"40093010233"},{"Id":399078,"FormularyType":"OHP","DrugName":"MELATONIN TAB 12MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007265","GenericName":"MELATONIN TABLET DISINTEGRATING 12 MG","NDC":"40093010234"},{"Id":399079,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"40093010242"},{"Id":399080,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"40093010282"},{"Id":399081,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"40093010305"},{"Id":399082,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"40093010306"},{"Id":399083,"FormularyType":"OHP","DrugName":"D3 HIGH POT CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"40093010323"},{"Id":399084,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"40093010328"},{"Id":399085,"FormularyType":"OHP","DrugName":"D3 HIGH POTE CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"40093010373"},{"Id":399086,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"40093010390"},{"Id":399087,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"40093010531"},{"Id":399088,"FormularyType":"OHP","DrugName":"CA CIT/VIT D TAB 315/250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"40093010583"},{"Id":399089,"FormularyType":"OHP","DrugName":"EASY IRON CAP 28MG","DosageForm":"CAPS - Capsule","Strength":"28","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300025000120","GenericName":"FERROUS BISGLYCINATE CHELATE CAPSULE 28 MG (ELEMENTAL IRON)","NDC":"40093010584"},{"Id":399090,"FormularyType":"OHP","DrugName":"B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"40093010588"},{"Id":399091,"FormularyType":"OHP","DrugName":"OYST CA/D3 TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"40093010596"},{"Id":399092,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"40093010600"},{"Id":399093,"FormularyType":"OHP","DrugName":"B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"40093010602"},{"Id":399094,"FormularyType":"OHP","DrugName":"HIGH POTENCY CAP E","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"40093010605"},{"Id":399095,"FormularyType":"OHP","DrugName":"FISH OIL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"40093010607"},{"Id":399096,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"40093010609"},{"Id":399097,"FormularyType":"OHP","DrugName":"D3 HIGH POTE TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"40093010618"},{"Id":399098,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"40093010646"},{"Id":399099,"FormularyType":"OHP","DrugName":"B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"40093010660"},{"Id":399100,"FormularyType":"OHP","DrugName":"B-12 TR TAB 1000 MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"40093011099"},{"Id":399101,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 10MG/ML","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000970","GenericName":"MELATONIN LIQUID 10 MG/ML","NDC":"40093011213"},{"Id":399102,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 10MG/ML","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000970","GenericName":"MELATONIN LIQUID 10 MG/ML","NDC":"40093011221"},{"Id":399103,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"40093011371"},{"Id":399104,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW EX STR","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"40093011526"},{"Id":399105,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"40093011543"},{"Id":399106,"FormularyType":"OHP","DrugName":"D3 HIGH POTE CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"40093014002"},{"Id":399107,"FormularyType":"OHP","DrugName":"D3 HP CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"40093014024"},{"Id":399108,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"40093014047"},{"Id":399109,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"40232038124"},{"Id":399110,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"40232045491"},{"Id":399111,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"40232060519"},{"Id":399112,"FormularyType":"OHP","DrugName":"B-12 TAB 1000 CR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"40985021104"},{"Id":399113,"FormularyType":"OHP","DrugName":"B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"40985021151"},{"Id":399114,"FormularyType":"OHP","DrugName":"B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"40985021196"},{"Id":399115,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"40985021240"},{"Id":399116,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"40985021364"},{"Id":399117,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"40985021377"},{"Id":399118,"FormularyType":"OHP","DrugName":"POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"40985021387"},{"Id":399119,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"40985021495"},{"Id":399120,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"40985022309"},{"Id":399121,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"40985022563"},{"Id":399122,"FormularyType":"OHP","DrugName":"CALCIUM/D CAP 600MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630150","GenericName":"CALCIUM CARBONATE-VITAMIN D CAP 600 MG-5 MCG (200 UNIT)","NDC":"40985022653"},{"Id":399123,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"40985022661"},{"Id":399124,"FormularyType":"OHP","DrugName":"B COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"40985022668"},{"Id":399125,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"40985022670"},{"Id":399126,"FormularyType":"OHP","DrugName":"IRON TAB 27MG","DosageForm":"TABS - Tablet","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"40985022690"},{"Id":399127,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"40985022721"},{"Id":399128,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"40985022731"},{"Id":399129,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG PR","DosageForm":"TBCR - Tablet ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000440","GenericName":"NIACIN TAB ER 250 MG","NDC":"40985022849"},{"Id":399130,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"40985022872"},{"Id":399131,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"40985022921"},{"Id":399132,"FormularyType":"OHP","DrugName":"PSYLLIUM FIB CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"40985027024"},{"Id":399133,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"40985027062"},{"Id":399134,"FormularyType":"OHP","DrugName":"MGO TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"40985027072"},{"Id":399135,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"40985027087"},{"Id":399136,"FormularyType":"OHP","DrugName":"D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"40985027111"},{"Id":399137,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"40985027139"},{"Id":399138,"FormularyType":"OHP","DrugName":"PRENATAL MV MIS + DHA","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006319","GenericName":"*PRENATAL W/FE FUM-FA TAB 28-0.8 MG & DHA CAP 200 MG PACK*","NDC":"40985027175"},{"Id":399139,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"40985027288"},{"Id":399140,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"40985027292"},{"Id":399141,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"40985027310"},{"Id":399142,"FormularyType":"OHP","DrugName":"ZOO FRIENDS CHW EXTRA C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"40985027313"},{"Id":399143,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"40985027348"},{"Id":399144,"FormularyType":"OHP","DrugName":"D3 CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"40985027380"},{"Id":399145,"FormularyType":"OHP","DrugName":"D3-1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"40985027415"},{"Id":399146,"FormularyType":"OHP","DrugName":"D3 SUPER STR CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"40985027416"},{"Id":399147,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG PR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"40985027474"},{"Id":399148,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"40985027492"},{"Id":399149,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"40985027493"},{"Id":399150,"FormularyType":"OHP","DrugName":"CALCIUM+D3 TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"40985027495"},{"Id":399151,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"40985027503"},{"Id":399152,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 10000UNT","DosageForm":"TABS - Tablet","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"40985027504"},{"Id":399153,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"40985027523"},{"Id":399154,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"40985027532"},{"Id":399155,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"40985027534"},{"Id":399156,"FormularyType":"OHP","DrugName":"VITAJOY DALY CHW D 1000IU","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"40985027622"},{"Id":399157,"FormularyType":"OHP","DrugName":"CALC CITR+D3 TAB 200-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"40985027709"},{"Id":399158,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000440","GenericName":"MELATONIN TAB ER 10 MG","NDC":"40985028028"},{"Id":399159,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"40985028037"},{"Id":399160,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163000102"},{"Id":399161,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163000171"},{"Id":399162,"FormularyType":"OHP","DrugName":"EQL ENEMA ENE RTU","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"41163000511"},{"Id":399163,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"41163004064"},{"Id":399164,"FormularyType":"OHP","DrugName":"EQL IBU PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"41163005058"},{"Id":399165,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"41163005705"},{"Id":399166,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"41163007502"},{"Id":399167,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"41163008100"},{"Id":399168,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW FRUIT","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"41163010116"},{"Id":399169,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW PEPPRMNT","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"41163010146"},{"Id":399170,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163010214"},{"Id":399171,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163010224"},{"Id":399172,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163010228"},{"Id":399173,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163010234"},{"Id":399174,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163010313"},{"Id":399175,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163010323"},{"Id":399176,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163010333"},{"Id":399177,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163010343"},{"Id":399178,"FormularyType":"OHP","DrugName":"EQL FIBER LA TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"41163012021"},{"Id":399179,"FormularyType":"OHP","DrugName":"EQL HEARTBRN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"41163014165"},{"Id":399180,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"41163019408"},{"Id":399181,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163019451"},{"Id":399182,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163019471"},{"Id":399183,"FormularyType":"OHP","DrugName":"EQL FIRSTAID OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"41163020958"},{"Id":399184,"FormularyType":"OHP","DrugName":"EQL FIRSTAID OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"41163020964"},{"Id":399185,"FormularyType":"OHP","DrugName":"EQL VIT E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"41163023117"},{"Id":399186,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"41163023154"},{"Id":399187,"FormularyType":"OHP","DrugName":"EQL ENEMA ENE RTU","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"41163023324"},{"Id":399188,"FormularyType":"OHP","DrugName":"EQL ENEMA ENE RTU","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"41163023325"},{"Id":399189,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW FRUIT","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"41163023346"},{"Id":399190,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"41163023351"},{"Id":399191,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163023364"},{"Id":399192,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163023365"},{"Id":399193,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163023367"},{"Id":399194,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163023368"},{"Id":399195,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163023369"},{"Id":399196,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163023379"},{"Id":399197,"FormularyType":"OHP","DrugName":"EQL PRENATAL TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"41163023569"},{"Id":399198,"FormularyType":"OHP","DrugName":"CAL SOFT CHW CHW MLK CHOC","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903400535","GenericName":"CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG","NDC":"41163023860"},{"Id":399199,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163024423"},{"Id":399200,"FormularyType":"OHP","DrugName":"EQL LAXATIVE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"41163024425"},{"Id":399201,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"41163024427"},{"Id":399202,"FormularyType":"OHP","DrugName":"EQL HEARTBRN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"41163024429"},{"Id":399203,"FormularyType":"OHP","DrugName":"EQL HEARTBRN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"41163024430"},{"Id":399204,"FormularyType":"OHP","DrugName":"EQL GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"41163024460"},{"Id":399205,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"41163024480"},{"Id":399206,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"41163025089"},{"Id":399207,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163025149"},{"Id":399208,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"41163025162"},{"Id":399209,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"41163025407"},{"Id":399210,"FormularyType":"OHP","DrugName":"EQL LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"41163025409"},{"Id":399211,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163025414"},{"Id":399212,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163025415"},{"Id":399213,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163025418"},{"Id":399214,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"41163025420"},{"Id":399215,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"41163025510"},{"Id":399216,"FormularyType":"OHP","DrugName":"EQL LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"41163025583"},{"Id":399217,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW PEPPRMNT","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"41163025597"},{"Id":399218,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"41163025600"},{"Id":399219,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"41163025601"},{"Id":399220,"FormularyType":"OHP","DrugName":"EQL ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"41163025617"},{"Id":399221,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163025622"},{"Id":399222,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163025628"},{"Id":399223,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"41163025650"},{"Id":399224,"FormularyType":"OHP","DrugName":"NIGHTTIME TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"41163025674"},{"Id":399225,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"41163025691"},{"Id":399226,"FormularyType":"OHP","DrugName":"ALCOHOL PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"41163026334"},{"Id":399227,"FormularyType":"OHP","DrugName":"EQL FIRSTAID OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"41163026366"},{"Id":399228,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"41163026369"},{"Id":399229,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163026371"},{"Id":399230,"FormularyType":"OHP","DrugName":"ANTI-ITCH OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"41163026372"},{"Id":399231,"FormularyType":"OHP","DrugName":"EQL B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"41163026606"},{"Id":399232,"FormularyType":"OHP","DrugName":"SLOW REL FE TAB 160MG CR","DosageForm":"TBCR - Tablet ER","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100410","GenericName":"FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT)","NDC":"41163026621"},{"Id":399233,"FormularyType":"OHP","DrugName":"EQL FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"41163026627"},{"Id":399234,"FormularyType":"OHP","DrugName":"EQL CALCIUM TAB W/VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"41163026673"},{"Id":399235,"FormularyType":"OHP","DrugName":"CALCIUM CITR TAB W/VIT D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"41163026678"},{"Id":399236,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"41163026757"},{"Id":399237,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"41163029208"},{"Id":399238,"FormularyType":"OHP","DrugName":"EQL MOTION TAB SICKNESS","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"41163030402"},{"Id":399239,"FormularyType":"OHP","DrugName":"EQL CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"41163030601"},{"Id":399240,"FormularyType":"OHP","DrugName":"EQL CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"41163030602"},{"Id":399241,"FormularyType":"OHP","DrugName":"EQL CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"41163030603"},{"Id":399242,"FormularyType":"OHP","DrugName":"EQL HEARTBRN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"41163031372"},{"Id":399243,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163031916"},{"Id":399244,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163031964"},{"Id":399245,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"41163032908"},{"Id":399246,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"41163032922"},{"Id":399247,"FormularyType":"OHP","DrugName":"NIGHTTIME TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"41163036706"},{"Id":399248,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163036964"},{"Id":399249,"FormularyType":"OHP","DrugName":"EQL MIGRAINE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"41163037471"},{"Id":399250,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"41163037926"},{"Id":399251,"FormularyType":"OHP","DrugName":"EQL MENSTRUA TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"41163039010"},{"Id":399252,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"41163040123"},{"Id":399253,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%PLS 10","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163040884"},{"Id":399254,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163041140"},{"Id":399255,"FormularyType":"OHP","DrugName":"SLOW REL FE TAB 160MG CR","DosageForm":"TBCR - Tablet ER","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100410","GenericName":"FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT)","NDC":"41163041153"},{"Id":399256,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163041183"},{"Id":399257,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163041618"},{"Id":399258,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163041776"},{"Id":399259,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"41163041798"},{"Id":399260,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"41163042326"},{"Id":399261,"FormularyType":"OHP","DrugName":"IRON SUPPLEM TAB THERAPY","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"41163042350"},{"Id":399262,"FormularyType":"OHP","DrugName":"NIGHTTIME TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"41163042853"},{"Id":399263,"FormularyType":"OHP","DrugName":"IRON SUPPLEM TAB THERAPY","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"41163042886"},{"Id":399264,"FormularyType":"OHP","DrugName":"EQL ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"41163043223"},{"Id":399265,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"41163043267"},{"Id":399266,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163043978"},{"Id":399267,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163043979"},{"Id":399268,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"41163043980"},{"Id":399269,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"41163044807"},{"Id":399270,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"41163045129"},{"Id":399271,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"41163045130"},{"Id":399272,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"41163045285"},{"Id":399273,"FormularyType":"OHP","DrugName":"EQL CALCIUM TAB W/VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"41163045745"},{"Id":399274,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"41163045827"},{"Id":399275,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"41163045839"},{"Id":399276,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"41163045866"},{"Id":399277,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"41163045872"},{"Id":399278,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"41163046025"},{"Id":399279,"FormularyType":"OHP","DrugName":"EQL IBU PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"41163046056"},{"Id":399280,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"41163046110"},{"Id":399281,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"41163046112"},{"Id":399282,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"41163046113"},{"Id":399283,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"41163046581"},{"Id":399284,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"41163046588"},{"Id":399285,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163046692"},{"Id":399286,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163046695"},{"Id":399287,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"41163046718"},{"Id":399288,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"41163046719"},{"Id":399289,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41163046723"},{"Id":399290,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163046724"},{"Id":399291,"FormularyType":"OHP","DrugName":"EQL MENSTRUA TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"41163046725"},{"Id":399292,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163046726"},{"Id":399293,"FormularyType":"OHP","DrugName":"SLEEP AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"41163046734"},{"Id":399294,"FormularyType":"OHP","DrugName":"EQL CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"41163046735"},{"Id":399295,"FormularyType":"OHP","DrugName":"EQL CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"41163046737"},{"Id":399296,"FormularyType":"OHP","DrugName":"EQL CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"41163046743"},{"Id":399297,"FormularyType":"OHP","DrugName":"EQL FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"41163046945"},{"Id":399298,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"41163047133"},{"Id":399299,"FormularyType":"OHP","DrugName":"EQL ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"41163047159"},{"Id":399300,"FormularyType":"OHP","DrugName":"ANTI-ITCH OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"41163047164"},{"Id":399301,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"41163047326"},{"Id":399302,"FormularyType":"OHP","DrugName":"EQL CALCIUM TAB CITR/D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"41163047484"},{"Id":399303,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"41163047523"},{"Id":399304,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"41163047526"},{"Id":399305,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"41163047540"},{"Id":399306,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163047558"},{"Id":399307,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"41163048255"},{"Id":399308,"FormularyType":"OHP","DrugName":"EQL VITAMIN CAP D3","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"41163048256"},{"Id":399309,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"41163048827"},{"Id":399310,"FormularyType":"OHP","DrugName":"NIGHTTIME TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"41163048831"},{"Id":399311,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"41163048833"},{"Id":399312,"FormularyType":"OHP","DrugName":"EQL B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"41163049000"},{"Id":399313,"FormularyType":"OHP","DrugName":"SUPER B COMP TAB /VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"41163049001"},{"Id":399314,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"41163049017"},{"Id":399315,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"41163049018"},{"Id":399316,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"41163049147"},{"Id":399317,"FormularyType":"OHP","DrugName":"EQL MIGRAINE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"41163049152"},{"Id":399318,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163049256"},{"Id":399319,"FormularyType":"OHP","DrugName":"EQL ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"41163049257"},{"Id":399320,"FormularyType":"OHP","DrugName":"SCALP RELIEF LIQ 3%","DosageForm":"LIQD - Liquid","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030000912","GenericName":"SALICYLIC ACID LIQUID 3%","NDC":"41163049414"},{"Id":399321,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"41163049507"},{"Id":399322,"FormularyType":"OHP","DrugName":"SUPER B COMP TAB VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"41163049511"},{"Id":399323,"FormularyType":"OHP","DrugName":"EQL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"41163049528"},{"Id":399324,"FormularyType":"OHP","DrugName":"EQL FIBER POW THERAPY","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"41163049529"},{"Id":399325,"FormularyType":"OHP","DrugName":"EQL GENTLE TAB LAXATIVE","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"41163049679"},{"Id":399326,"FormularyType":"OHP","DrugName":"EQL GENTLE TAB LAXATIVE","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"41163049680"},{"Id":399327,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41163049699"},{"Id":399328,"FormularyType":"OHP","DrugName":"EQL MOTION TAB SICKNESS","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"41163049711"},{"Id":399329,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"41163049712"},{"Id":399330,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"41163049713"},{"Id":399331,"FormularyType":"OHP","DrugName":"VIT D3 GUMM CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"41163049808"},{"Id":399332,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB CHLDRN","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"41163049849"},{"Id":399333,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163050001"},{"Id":399334,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163050004"},{"Id":399335,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163050006"},{"Id":399336,"FormularyType":"OHP","DrugName":"EQL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"41163051372"},{"Id":399337,"FormularyType":"OHP","DrugName":"EQL ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"41163051402"},{"Id":399338,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163052001"},{"Id":399339,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41163052003"},{"Id":399340,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41163056306"},{"Id":399341,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41163056317"},{"Id":399342,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41163056332"},{"Id":399343,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB CHLDRN","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"41163058544"},{"Id":399344,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163060462"},{"Id":399345,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163060471"},{"Id":399346,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163060478"},{"Id":399347,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163060485"},{"Id":399348,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163060490"},{"Id":399349,"FormularyType":"OHP","DrugName":"EQL GENTLE TAB LAXATIVE","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"41163060752"},{"Id":399350,"FormularyType":"OHP","DrugName":"EQL GENTLE TAB LAXATIVE","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"41163060756"},{"Id":399351,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163061246"},{"Id":399352,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163061265"},{"Id":399353,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163061272"},{"Id":399354,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41163061275"},{"Id":399355,"FormularyType":"OHP","DrugName":"EQL LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"41163062518"},{"Id":399356,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163064771"},{"Id":399357,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41163064778"},{"Id":399358,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"41163068526"},{"Id":399359,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"41163070938"},{"Id":399360,"FormularyType":"OHP","DrugName":"EQL ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"41163079707"},{"Id":399361,"FormularyType":"OHP","DrugName":"ALCOHOL PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"41163081630"},{"Id":399362,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"41163082529"},{"Id":399363,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"41163089726"},{"Id":399364,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"41163091807"},{"Id":399365,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"41163091899"},{"Id":399366,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41163094532"},{"Id":399367,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%PLS 10","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41163097364"},{"Id":399368,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000210"},{"Id":399369,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000215"},{"Id":399370,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE MOISTURE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000220"},{"Id":399371,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE MOISTURE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000225"},{"Id":399372,"FormularyType":"OHP","DrugName":"CORTIZONE-10 OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"41167000250"},{"Id":399373,"FormularyType":"OHP","DrugName":"CORTIZONE-10 OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"41167000255"},{"Id":399374,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE ULTRA 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000270"},{"Id":399375,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE ULTRA 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000275"},{"Id":399376,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE PLUS","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000280"},{"Id":399377,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE MOISTURE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000351"},{"Id":399378,"FormularyType":"OHP","DrugName":"CORTIZONE-10 CRE ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"41167000397"},{"Id":399379,"FormularyType":"OHP","DrugName":"CORTIZONE-10 LOT ECZEMA","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"41167003310"},{"Id":399380,"FormularyType":"OHP","DrugName":"SELSUN BLUE SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"41167061803"},{"Id":399381,"FormularyType":"OHP","DrugName":"CAPZASIN-HP CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"41167075146"},{"Id":399382,"FormularyType":"OHP","DrugName":"NASACORT ALR SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"41167580002"},{"Id":399383,"FormularyType":"OHP","DrugName":"NASACORT ALR SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"41167580003"},{"Id":399384,"FormularyType":"OHP","DrugName":"NASACORT ALR SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"41167580005"},{"Id":399385,"FormularyType":"OHP","DrugName":"INCONTROL PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"41220025474"},{"Id":399386,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"41220052036"},{"Id":399387,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"41220052037"},{"Id":399388,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"41220052066"},{"Id":399389,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"41220052068"},{"Id":399390,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"41220052082"},{"Id":399391,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"41220052086"},{"Id":399392,"FormularyType":"OHP","DrugName":"INCONTROL MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"41220067800"},{"Id":399393,"FormularyType":"OHP","DrugName":"INCONTROL MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"41220067804"},{"Id":399394,"FormularyType":"OHP","DrugName":"INCONTROL MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"41220071937"},{"Id":399395,"FormularyType":"OHP","DrugName":"ORAL ELECTRO SOL H-E-B","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"41220087466"},{"Id":399396,"FormularyType":"OHP","DrugName":"UNIFINE PLUS MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"41220094075"},{"Id":399397,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41220094752"},{"Id":399398,"FormularyType":"OHP","DrugName":"IN CONTROL MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"41220098133"},{"Id":399399,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"41250002101"},{"Id":399400,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"41250002996"},{"Id":399401,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD EX-THICK","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"41250004081"},{"Id":399402,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD EX-THICK","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"41250004082"},{"Id":399403,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"41250005460"},{"Id":399404,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"41250011811"},{"Id":399405,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"41250017096"},{"Id":399406,"FormularyType":"OHP","DrugName":"ASA FREE CHW 160MG JR","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"41250017262"},{"Id":399407,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"41250019003"},{"Id":399408,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"41250019005"},{"Id":399409,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"41250020105"},{"Id":399410,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"41250020629"},{"Id":399411,"FormularyType":"OHP","DrugName":"CA CITRATE + TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"41250020735"},{"Id":399412,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"41250031152"},{"Id":399413,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"41250034410"},{"Id":399414,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"41250034411"},{"Id":399415,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"41250035740"},{"Id":399416,"FormularyType":"OHP","DrugName":"MIGRAINE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"41250037471"},{"Id":399417,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"41250037926"},{"Id":399418,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"41250037934"},{"Id":399419,"FormularyType":"OHP","DrugName":"CHLD ASAFREE ELX 80/2.5ML","DosageForm":"ELIX - Elixir","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001015","GenericName":"ACETAMINOPHEN ELIXIR 160 MG/5ML","NDC":"41250039326"},{"Id":399420,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"41250042229"},{"Id":399421,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"41250042405"},{"Id":399422,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"41250042978"},{"Id":399423,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"41250043262"},{"Id":399424,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"41250043267"},{"Id":399425,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"41250043280"},{"Id":399426,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"41250045606"},{"Id":399427,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"41250045670"},{"Id":399428,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"41250045678"},{"Id":399429,"FormularyType":"OHP","DrugName":"ALLERGY 24HR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"41250045875"},{"Id":399430,"FormularyType":"OHP","DrugName":"CHILD ALLRGY SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"41250047526"},{"Id":399431,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41250048471"},{"Id":399432,"FormularyType":"OHP","DrugName":"ASPIRIN FREE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"41250051055"},{"Id":399433,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"41250052048"},{"Id":399434,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"41250052049"},{"Id":399435,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41250052114"},{"Id":399436,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"41250052127"},{"Id":399437,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"41250052129"},{"Id":399438,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"41250052357"},{"Id":399439,"FormularyType":"OHP","DrugName":"ANTIHISTAMIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"41250052358"},{"Id":399440,"FormularyType":"OHP","DrugName":"REALITY MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"41250052813"},{"Id":399441,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"41250053206"},{"Id":399442,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"41250053270"},{"Id":399443,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"41250053278"},{"Id":399444,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"41250056025"},{"Id":399445,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"41250056587"},{"Id":399446,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"41250056588"},{"Id":399447,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"41250060098"},{"Id":399448,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"41250060478"},{"Id":399449,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"41250063126"},{"Id":399450,"FormularyType":"OHP","DrugName":"REALITY SWAB PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"41250064279"},{"Id":399451,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"41250064332"},{"Id":399452,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"41250064926"},{"Id":399453,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"41250066738"},{"Id":399454,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"41250067394"},{"Id":399455,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"41250070005"},{"Id":399456,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"41250073402"},{"Id":399457,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"41250080952"},{"Id":399458,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"41250080960"},{"Id":399459,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"41250082913"},{"Id":399460,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"41250087310"},{"Id":399461,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"41250087311"},{"Id":399462,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"41250087540"},{"Id":399463,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"41250093187"},{"Id":399464,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"41250093188"},{"Id":399465,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"41250094616"},{"Id":399466,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"41250095702"},{"Id":399467,"FormularyType":"OHP","DrugName":"CHILD ASA CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"41250096634"},{"Id":399468,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"41250096647"},{"Id":399469,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"41250098622"},{"Id":399470,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"41260000722"},{"Id":399471,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"41260000723"},{"Id":399472,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"41260000777"},{"Id":399473,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"41260000778"},{"Id":399474,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"41260000779"},{"Id":399475,"FormularyType":"OHP","DrugName":"PUR-ABSORB SOL 5MG/20ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002002","GenericName":"FERROUS SULFATE SOLN 5 MG/20ML (ELEMENTAL IRON)","NDC":"41273005083"},{"Id":399476,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"41405130301"},{"Id":399477,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"41405130310"},{"Id":399478,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"41405130801"},{"Id":399479,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"41405130810"},{"Id":399480,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"41405131801"},{"Id":399481,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"41405131810"},{"Id":399482,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"41405330301"},{"Id":399483,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"41405330310"},{"Id":399484,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"41405330801"},{"Id":399485,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"41405330810"},{"Id":399486,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"41405331801"},{"Id":399487,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"41405331810"},{"Id":399488,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"41405530301"},{"Id":399489,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"41405530310"},{"Id":399490,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"41405530801"},{"Id":399491,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"41405530810"},{"Id":399492,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"41405531801"},{"Id":399493,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"41405531810"},{"Id":399494,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"41415001778"},{"Id":399495,"FormularyType":"OHP","DrugName":"MODULEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"41470000530"},{"Id":399496,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"41520000139"},{"Id":399497,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"41520000140"},{"Id":399498,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"41520000141"},{"Id":399499,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"41520000142"},{"Id":399500,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"41520000143"},{"Id":399501,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"41520000144"},{"Id":399502,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"41520000587"},{"Id":399503,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015781"},{"Id":399504,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015782"},{"Id":399505,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015790"},{"Id":399506,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015791"},{"Id":399507,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015792"},{"Id":399508,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015810"},{"Id":399509,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015811"},{"Id":399510,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679015812"},{"Id":399511,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679028087"},{"Id":399512,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679037233"},{"Id":399513,"FormularyType":"OHP","DrugName":"GLUCOSE CTRL LIQ MAX PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679037424"},{"Id":399514,"FormularyType":"OHP","DrugName":"BOOST WOMEN LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679047337"},{"Id":399515,"FormularyType":"OHP","DrugName":"BOOST WOMEN LIQ CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679047371"},{"Id":399516,"FormularyType":"OHP","DrugName":"BOOST WOMEN LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679047373"},{"Id":399517,"FormularyType":"OHP","DrugName":"BOOST WOMEN LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679047377"},{"Id":399518,"FormularyType":"OHP","DrugName":"BOOST WOMEN LIQ CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679047713"},{"Id":399519,"FormularyType":"OHP","DrugName":"BOOST WOMEN LIQ CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679047731"},{"Id":399520,"FormularyType":"OHP","DrugName":"BOOST MAX LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679053034"},{"Id":399521,"FormularyType":"OHP","DrugName":"GLUCOSE CTRL LIQ MAX PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679053380"},{"Id":399522,"FormularyType":"OHP","DrugName":"GLUCOSE CTRL LIQ MAX PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679057234"},{"Id":399523,"FormularyType":"OHP","DrugName":"GLUCOSE CTRL LIQ MAX PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679066380"},{"Id":399524,"FormularyType":"OHP","DrugName":"BOOST LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067400"},{"Id":399525,"FormularyType":"OHP","DrugName":"BOOST LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067436"},{"Id":399526,"FormularyType":"OHP","DrugName":"BOOST LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067466"},{"Id":399527,"FormularyType":"OHP","DrugName":"BOOST LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067500"},{"Id":399528,"FormularyType":"OHP","DrugName":"BOOST LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067501"},{"Id":399529,"FormularyType":"OHP","DrugName":"BOOST LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067566"},{"Id":399530,"FormularyType":"OHP","DrugName":"BOOST LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067600"},{"Id":399531,"FormularyType":"OHP","DrugName":"BOOST LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067636"},{"Id":399532,"FormularyType":"OHP","DrugName":"BOOST LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679067666"},{"Id":399533,"FormularyType":"OHP","DrugName":"GLUCOSE CTRL LIQ MAX PROT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679079450"},{"Id":399534,"FormularyType":"OHP","DrugName":"BOOST LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679080218"},{"Id":399535,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ VRY VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679093100"},{"Id":399536,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679093166"},{"Id":399537,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679093266"},{"Id":399538,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679093366"},{"Id":399539,"FormularyType":"OHP","DrugName":"BOOST HI-PRO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679094036"},{"Id":399540,"FormularyType":"OHP","DrugName":"BOOST HI-PRO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679094066"},{"Id":399541,"FormularyType":"OHP","DrugName":"BOOST HI-PRO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679094136"},{"Id":399542,"FormularyType":"OHP","DrugName":"BOOST HI-PRO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679094166"},{"Id":399543,"FormularyType":"OHP","DrugName":"BOOST HI-PRO LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679094466"},{"Id":399544,"FormularyType":"OHP","DrugName":"BOOST LIQ ORIGINAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"41679096427"},{"Id":399545,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"42023020101"},{"Id":399546,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 200MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102107","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 200 MCG","NDC":"42023020201"},{"Id":399547,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 500MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102112","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 500 MCG","NDC":"42023020301"},{"Id":399548,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"42023022101"},{"Id":399549,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"42023022110"},{"Id":399550,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"42023022185"},{"Id":399551,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"42023022189"},{"Id":399552,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"42023022401"},{"Id":399553,"FormularyType":"OHP","DrugName":"ECOTRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"42037010312"},{"Id":399554,"FormularyType":"OHP","DrugName":"ECOTRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"42037010313"},{"Id":399555,"FormularyType":"OHP","DrugName":"ECOTRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"42037010375"},{"Id":399556,"FormularyType":"OHP","DrugName":"ECOTRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"42037010379"},{"Id":399557,"FormularyType":"OHP","DrugName":"ECOTRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"42037010427"},{"Id":399558,"FormularyType":"OHP","DrugName":"PNV-SELECT TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512022000320","GenericName":"*PRENATAL VIT W/ FE FUM-METHYLFOLATE-FA TAB 27-0.6-0.4 MG***","NDC":"42192032090"},{"Id":399559,"FormularyType":"OHP","DrugName":"NP THYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"42192032701"},{"Id":399560,"FormularyType":"OHP","DrugName":"NP THYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"42192032730"},{"Id":399561,"FormularyType":"OHP","DrugName":"NP THYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"42192032790"},{"Id":399562,"FormularyType":"OHP","DrugName":"NP THYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"42192032801"},{"Id":399563,"FormularyType":"OHP","DrugName":"NP THYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"42192032830"},{"Id":399564,"FormularyType":"OHP","DrugName":"NP THYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"42192032890"},{"Id":399565,"FormularyType":"OHP","DrugName":"NP THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"42192032901"},{"Id":399566,"FormularyType":"OHP","DrugName":"NP THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"42192032910"},{"Id":399567,"FormularyType":"OHP","DrugName":"NP THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"42192032930"},{"Id":399568,"FormularyType":"OHP","DrugName":"NP THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"42192032990"},{"Id":399569,"FormularyType":"OHP","DrugName":"NP THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"42192033001"},{"Id":399570,"FormularyType":"OHP","DrugName":"NP THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"42192033010"},{"Id":399571,"FormularyType":"OHP","DrugName":"NP THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"42192033030"},{"Id":399572,"FormularyType":"OHP","DrugName":"NP THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"42192033090"},{"Id":399573,"FormularyType":"OHP","DrugName":"NP THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"42192033101"},{"Id":399574,"FormularyType":"OHP","DrugName":"NP THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"42192033110"},{"Id":399575,"FormularyType":"OHP","DrugName":"NP THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"42192033130"},{"Id":399576,"FormularyType":"OHP","DrugName":"NP THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"42192033190"},{"Id":399577,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"42192034001"},{"Id":399578,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"42192050105"},{"Id":399579,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"42192060805"},{"Id":399580,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 300/6ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"42192060806"},{"Id":399581,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"42192060816"},{"Id":399582,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 300/6ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"42192060840"},{"Id":399583,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"42192060845"},{"Id":399584,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"42192061402"},{"Id":399585,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"42192061405"},{"Id":399586,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"42192061410"},{"Id":399587,"FormularyType":"OHP","DrugName":"PHENYTOIN INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030052005","GenericName":"PHENYTOIN SODIUM INJ 50 MG/ML","NDC":"42192061430"},{"Id":399588,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"42192062616"},{"Id":399589,"FormularyType":"OHP","DrugName":"CICLOPIROX SOL 8%","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030002020","GenericName":"CICLOPIROX SOLUTION 8%","NDC":"42192071506"},{"Id":399590,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100012102020","GenericName":"CIPROFLOXACIN HCL OTIC SOLN 0.2% (BASE EQUIVALENT)","NDC":"42195055014"},{"Id":399591,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"42291003360"},{"Id":399592,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"42291003460"},{"Id":399593,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"42291003690"},{"Id":399594,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"42291003790"},{"Id":399595,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"42291003890"},{"Id":399596,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"42291003990"},{"Id":399597,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"42291004090"},{"Id":399598,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"42291004190"},{"Id":399599,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"42291007101"},{"Id":399600,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"42291007615"},{"Id":399601,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"42291007630"},{"Id":399602,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"42291007645"},{"Id":399603,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"42291007660"},{"Id":399604,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"42291007715"},{"Id":399605,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"42291007730"},{"Id":399606,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"42291007745"},{"Id":399607,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"42291007760"},{"Id":399608,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000110","GenericName":"ACITRETIN CAP 10 MG","NDC":"42291008630"},{"Id":399609,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 17.5MG","DosageForm":"CAPS - Capsule","Strength":"17.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000115","GenericName":"ACITRETIN CAP 17.5 MG","NDC":"42291008730"},{"Id":399610,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000125","GenericName":"ACITRETIN CAP 25 MG","NDC":"42291008830"},{"Id":399611,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"42291009430"},{"Id":399612,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"42291020850"},{"Id":399613,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"42291020950"},{"Id":399614,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"42291031001"},{"Id":399615,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"42291042642"},{"Id":399616,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"42291045490"},{"Id":399617,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"42291045590"},{"Id":399618,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"42291047101"},{"Id":399619,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"42291047150"},{"Id":399620,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000320","GenericName":"ETRAVIRINE TAB 100 MG","NDC":"42291047312"},{"Id":399621,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000340","GenericName":"ETRAVIRINE TAB 200 MG","NDC":"42291047460"},{"Id":399622,"FormularyType":"OHP","DrugName":"ETONOGESTREL MIS ETHY EST","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"42291047803"},{"Id":399623,"FormularyType":"OHP","DrugName":"PIRFENIDONE CAP 267MG","DosageForm":"CAPS - Capsule","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000120","GenericName":"PIRFENIDONE CAP 267 MG","NDC":"42291049027"},{"Id":399624,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"42291049109"},{"Id":399625,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"42291049127"},{"Id":399626,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"42291049209"},{"Id":399627,"FormularyType":"OHP","DrugName":"NALOXONE SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"42291049301"},{"Id":399628,"FormularyType":"OHP","DrugName":"NALOXONE SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"42291049302"},{"Id":399629,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"42291050901"},{"Id":399630,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"42291050950"},{"Id":399631,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"42291055328"},{"Id":399632,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"42291055384"},{"Id":399633,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"42291056528"},{"Id":399634,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"42291056584"},{"Id":399635,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"42291056760"},{"Id":399636,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"42291059028"},{"Id":399637,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"42291059084"},{"Id":399638,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"42291066410"},{"Id":399639,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"42291066610"},{"Id":399640,"FormularyType":"OHP","DrugName":"SODIUM FLUOR CRE 1.1%","DosageForm":"CREA - Cream","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020003721","GenericName":"SODIUM FLUORIDE CREAM 1.1%","NDC":"42291074151"},{"Id":399641,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"42291076401"},{"Id":399642,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"42291077630"},{"Id":399643,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"42291078142"},{"Id":399644,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"42291078401"},{"Id":399645,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"42291078430"},{"Id":399646,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"42291078501"},{"Id":399647,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"42291078530"},{"Id":399648,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"42291079030"},{"Id":399649,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"42291079130"},{"Id":399650,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"42291079230"},{"Id":399651,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"42291085630"},{"Id":399652,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"42291085790"},{"Id":399653,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"42291085890"},{"Id":399654,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"42291085990"},{"Id":399655,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"42291092756"},{"Id":399656,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"42291092856"},{"Id":399657,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"42291092953"},{"Id":399658,"FormularyType":"OHP","DrugName":"ZAFEMY DIS 150/35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"42291093001"},{"Id":399659,"FormularyType":"OHP","DrugName":"ZAFEMY DIS 150/35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"42291093003"},{"Id":399660,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"42291093790"},{"Id":399661,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"42291094090"},{"Id":399662,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"42291094190"},{"Id":399663,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"42291094290"},{"Id":399664,"FormularyType":"OHP","DrugName":"YUVAFEM TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"42291096208"},{"Id":399665,"FormularyType":"OHP","DrugName":"YUVAFEM TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"42291096218"},{"Id":399666,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"42291098910"},{"Id":399667,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"42292003801"},{"Id":399668,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"42292003820"},{"Id":399669,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"42292003901"},{"Id":399670,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"42292003920"},{"Id":399671,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"42292004001"},{"Id":399672,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"42292004020"},{"Id":399673,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"42292004101"},{"Id":399674,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"42292004120"},{"Id":399675,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"42292004301"},{"Id":399676,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"42292004303"},{"Id":399677,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"42292004401"},{"Id":399678,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"42292004403"},{"Id":399679,"FormularyType":"OHP","DrugName":"EMTRIC/RILPI TAB TENOF DF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903400320","GenericName":"EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB 200-25-300 MG","NDC":"42385080130"},{"Id":399680,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"42385090103"},{"Id":399681,"FormularyType":"OHP","DrugName":"EFAVIR/EMTRI TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903300320","GenericName":"EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG","NDC":"42385091530"},{"Id":399682,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200130","GenericName":"ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV)","NDC":"42385092060"},{"Id":399683,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200140","GenericName":"ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV)","NDC":"42385092160"},{"Id":399684,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200150","GenericName":"ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV)","NDC":"42385092230"},{"Id":399685,"FormularyType":"OHP","DrugName":"PIRFENIDONE CAP 267MG","DosageForm":"CAPS - Capsule","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000120","GenericName":"PIRFENIDONE CAP 267 MG","NDC":"42385092329"},{"Id":399686,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"42385092499"},{"Id":399687,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 534MG","DosageForm":"TABS - Tablet","Strength":"534","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000333","GenericName":"PIRFENIDONE TAB 534 MG","NDC":"42385092590"},{"Id":399688,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"42385092690"},{"Id":399689,"FormularyType":"OHP","DrugName":"EFAVIR/LAMIV TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903330340","GenericName":"EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 600-300-300 MG","NDC":"42385092830"},{"Id":399690,"FormularyType":"OHP","DrugName":"EFAVIR/LAMIV TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903330330","GenericName":"EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 400-300-300 MG","NDC":"42385092931"},{"Id":399691,"FormularyType":"OHP","DrugName":"LOPIN/RITON TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902550310","GenericName":"LOPINAVIR-RITONAVIR TAB 100-25 MG","NDC":"42385093360"},{"Id":399692,"FormularyType":"OHP","DrugName":"LOPIN/RITON TAB 200-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902550320","GenericName":"LOPINAVIR-RITONAVIR TAB 200-50 MG","NDC":"42385093412"},{"Id":399693,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"42385093590"},{"Id":399694,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"42385093605"},{"Id":399695,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"42385093690"},{"Id":399696,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"42385094001"},{"Id":399697,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"42385094005"},{"Id":399698,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"42385094011"},{"Id":399699,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"42385094090"},{"Id":399700,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"42385094101"},{"Id":399701,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"42385094105"},{"Id":399702,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"42385094111"},{"Id":399703,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"42385094190"},{"Id":399704,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"42385094201"},{"Id":399705,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"42385094205"},{"Id":399706,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"42385094211"},{"Id":399707,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"42385094290"},{"Id":399708,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"42385094301"},{"Id":399709,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"42385094305"},{"Id":399710,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"42385094311"},{"Id":399711,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"42385094390"},{"Id":399712,"FormularyType":"OHP","DrugName":"FENOFIBRIC CAP 45MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200006006520","GenericName":"CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV)","NDC":"42385094490"},{"Id":399713,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"42385094601"},{"Id":399714,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"42385094701"},{"Id":399715,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"42385094705"},{"Id":399716,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"42385094711"},{"Id":399717,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"42385094801"},{"Id":399718,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"42385094805"},{"Id":399719,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"42385094811"},{"Id":399720,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"42385094901"},{"Id":399721,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"42385094905"},{"Id":399722,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"42385094911"},{"Id":399723,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"42385095330"},{"Id":399724,"FormularyType":"OHP","DrugName":"ABACA/LAMIVU TAB 600-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902200340","GenericName":"ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG","NDC":"42385096230"},{"Id":399725,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42385097201"},{"Id":399726,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42385097205"},{"Id":399727,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42385097211"},{"Id":399728,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42385097301"},{"Id":399729,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42385097305"},{"Id":399730,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42385097311"},{"Id":399731,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42385097401"},{"Id":399732,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42385097405"},{"Id":399733,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42385097411"},{"Id":399734,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"42385097701"},{"Id":399735,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"42385097705"},{"Id":399736,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"42385097711"},{"Id":399737,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"42385097790"},{"Id":399738,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"42385097801"},{"Id":399739,"FormularyType":"OHP","DrugName":"COMETRIQ KIT 140MG","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010106480","GenericName":"CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 X 20 MG (140 DOSE) KIT","NDC":"42388001114"},{"Id":399740,"FormularyType":"OHP","DrugName":"COMETRIQ KIT 100MG","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010106470","GenericName":"CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT","NDC":"42388001214"},{"Id":399741,"FormularyType":"OHP","DrugName":"COMETRIQ KIT 60MG","DosageForm":"KIT - Kit","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010106460","GenericName":"CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT","NDC":"42388001314"},{"Id":399742,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100340","GenericName":"CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT)","NDC":"42388002326"},{"Id":399743,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100340","GenericName":"CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT)","NDC":"42388002336"},{"Id":399744,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100340","GenericName":"CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT)","NDC":"42388002346"},{"Id":399745,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100320","GenericName":"CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT)","NDC":"42388002426"},{"Id":399746,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100320","GenericName":"CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT)","NDC":"42388002446"},{"Id":399747,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100330","GenericName":"CABOZANTINIB S-MALATE TAB 40 MG (BASE EQUIVALENT)","NDC":"42388002526"},{"Id":399748,"FormularyType":"OHP","DrugName":"CABOMETYX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533010100330","GenericName":"CABOZANTINIB S-MALATE TAB 40 MG (BASE EQUIVALENT)","NDC":"42388002546"},{"Id":399749,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD MED 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"42423027001"},{"Id":399750,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD MED 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"42423027002"},{"Id":399751,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD MED 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"42423027101"},{"Id":399752,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD MED 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"42423027102"},{"Id":399753,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD MED 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"42423027103"},{"Id":399754,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD MED 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"42423027104"},{"Id":399755,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000307","GenericName":"CHLORZOXAZONE TAB 375 MG","NDC":"42494042506"},{"Id":399756,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"42494045020"},{"Id":399757,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"42494045050"},{"Id":399758,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"42494045120"},{"Id":399759,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"42494045150"},{"Id":399760,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"42494045730"},{"Id":399761,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"42494045830"},{"Id":399762,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"42507032910"},{"Id":399763,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"42507033240"},{"Id":399764,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"42507039640"},{"Id":399765,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"42507040378"},{"Id":399766,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"42507048547"},{"Id":399767,"FormularyType":"OHP","DrugName":"IXIARO INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100025101800","GenericName":"JAPANESE ENCEPHALITIS VACCINE INACTIVATED ADSORBED INJ","NDC":"42515000201"},{"Id":399768,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"42543040601"},{"Id":399769,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"42543040701"},{"Id":399770,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"42543040801"},{"Id":399771,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"42543049301"},{"Id":399772,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"42543049305"},{"Id":399773,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"42543049701"},{"Id":399774,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"42543049705"},{"Id":399775,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"42543071904"},{"Id":399776,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"42543096407"},{"Id":399777,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"42543096507"},{"Id":399778,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"42543096607"},{"Id":399779,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"42543097025"},{"Id":399780,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"42543097106"},{"Id":399781,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"42543097206"},{"Id":399782,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"42543098807"},{"Id":399783,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"42543098907"},{"Id":399784,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040004010","GenericName":"METRONIDAZOLE GEL 0.75%","NDC":"42546070045"},{"Id":399785,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"42546072045"},{"Id":399786,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"42571010001"},{"Id":399787,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"42571010005"},{"Id":399788,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"42571010101"},{"Id":399789,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"42571010105"},{"Id":399790,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"42571010301"},{"Id":399791,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"42571010305"},{"Id":399792,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"42571011010"},{"Id":399793,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"42571011090"},{"Id":399794,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"42571011190"},{"Id":399795,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"42571011210"},{"Id":399796,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"42571011290"},{"Id":399797,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"42571011901"},{"Id":399798,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"42571011905"},{"Id":399799,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"42571012821"},{"Id":399800,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"42571012828"},{"Id":399801,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"42571012835"},{"Id":399802,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"42571013021"},{"Id":399803,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"42571013027"},{"Id":399804,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"42571013725"},{"Id":399805,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"42571013726"},{"Id":399806,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"42571014126"},{"Id":399807,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"42571014301"},{"Id":399808,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"42571014305"},{"Id":399809,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"42571014401"},{"Id":399810,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"42571014405"},{"Id":399811,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"42571014726"},{"Id":399812,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 250-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200310","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 250-125 MG","NDC":"42571016030"},{"Id":399813,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"42571016101"},{"Id":399814,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"42571016142"},{"Id":399815,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"42571016201"},{"Id":399816,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"42571016242"},{"Id":399817,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"42571017210"},{"Id":399818,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"42571017290"},{"Id":399819,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"42571017310"},{"Id":399820,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"42571017390"},{"Id":399821,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"42571017410"},{"Id":399822,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"42571017490"},{"Id":399823,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"42571017510"},{"Id":399824,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"42571017590"},{"Id":399825,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"42571022630"},{"Id":399826,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"42571022730"},{"Id":399827,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"42571022830"},{"Id":399828,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"42571023401"},{"Id":399829,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"42571023405"},{"Id":399830,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"42571024301"},{"Id":399831,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"42571024469"},{"Id":399832,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100105","GenericName":"CLINDAMYCIN HCL CAP 75 MG","NDC":"42571025001"},{"Id":399833,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"42571025101"},{"Id":399834,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"42571025201"},{"Id":399835,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"42571025930"},{"Id":399836,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"42571027460"},{"Id":399837,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"42571027560"},{"Id":399838,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"42571031386"},{"Id":399839,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"42571031387"},{"Id":399840,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"42571031396"},{"Id":399841,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"42571031397"},{"Id":399842,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"42571031501"},{"Id":399843,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"42571031601"},{"Id":399844,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"42571033539"},{"Id":399845,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"42571033690"},{"Id":399846,"FormularyType":"OHP","DrugName":"FENOFIBRIC CAP 45MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200006006520","GenericName":"CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV)","NDC":"42571034790"},{"Id":399847,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"42571035707"},{"Id":399848,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"42571035807"},{"Id":399849,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"42571036281"},{"Id":399850,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"42571036299"},{"Id":399851,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"42571036983"},{"Id":399852,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"42571037501"},{"Id":399853,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"42571037530"},{"Id":399854,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN SOL 2%","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051020002010","GenericName":"ERYTHROMYCIN SOLN 2%","NDC":"42571038425"},{"Id":399855,"FormularyType":"OHP","DrugName":"TRIAMCINOLON LOT 0.1%","DosageForm":"LOTN - Lotion","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104110","GenericName":"TRIAMCINOLONE ACETONIDE LOTION 0.1%","NDC":"42571038519"},{"Id":399856,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"42571040421"},{"Id":399857,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"42571040488"},{"Id":399858,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"42571040819"},{"Id":399859,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"42571040892"},{"Id":399860,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"42571043345"},{"Id":399861,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"42582011110"},{"Id":399862,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"42582011118"},{"Id":399863,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"42582011210"},{"Id":399864,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"42582011218"},{"Id":399865,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"42582011310"},{"Id":399866,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"42582011318"},{"Id":399867,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42582011410"},{"Id":399868,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42582011418"},{"Id":399869,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42582011510"},{"Id":399870,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42582011518"},{"Id":399871,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42582011610"},{"Id":399872,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42582011618"},{"Id":399873,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"42582021110"},{"Id":399874,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"42582021118"},{"Id":399875,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"42582021210"},{"Id":399876,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"42582021218"},{"Id":399877,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"42582021310"},{"Id":399878,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"42582021318"},{"Id":399879,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"42582021410"},{"Id":399880,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"42582021418"},{"Id":399881,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"42582021605"},{"Id":399882,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"42582021618"},{"Id":399883,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"42582031109"},{"Id":399884,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"42582031130"},{"Id":399885,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"42582031209"},{"Id":399886,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"42582031230"},{"Id":399887,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"42582031309"},{"Id":399888,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"42582031318"},{"Id":399889,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"42582031409"},{"Id":399890,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"42582031418"},{"Id":399891,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"42582031509"},{"Id":399892,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"42582031518"},{"Id":399893,"FormularyType":"OHP","DrugName":"POLYSAC-IRON CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"42582041110"},{"Id":399894,"FormularyType":"OHP","DrugName":"MICROLIFE MIS PEAK FLO","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"42632073200"},{"Id":399895,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"42658012101"},{"Id":399896,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"42658012104"},{"Id":399897,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"42658012201"},{"Id":399898,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"42658012204"},{"Id":399899,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"42658012301"},{"Id":399900,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"42658012304"},{"Id":399901,"FormularyType":"OHP","DrugName":"ADEFOV DIPIV TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352015100320","GenericName":"ADEFOVIR DIPIVOXIL TAB 10 MG","NDC":"42794000308"},{"Id":399902,"FormularyType":"OHP","DrugName":"AMILORIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500010100305","GenericName":"AMILORIDE HCL TAB 5 MG","NDC":"42794000502"},{"Id":399903,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000105","GenericName":"FLUCYTOSINE CAP 250 MG","NDC":"42794000908"},{"Id":399904,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000110","GenericName":"FLUCYTOSINE CAP 500 MG","NDC":"42794001008"},{"Id":399905,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"42794001802"},{"Id":399906,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"42794001806"},{"Id":399907,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"42794001812"},{"Id":399908,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"42794001902"},{"Id":399909,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"42794001906"},{"Id":399910,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"42794001912"},{"Id":399911,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"42794002002"},{"Id":399912,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"42794002012"},{"Id":399913,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000325","GenericName":"DISULFIRAM TAB 250 MG","NDC":"42794002808"},{"Id":399914,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000350","GenericName":"DISULFIRAM TAB 500 MG","NDC":"42794002908"},{"Id":399915,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"42794004410"},{"Id":399916,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"42794004510"},{"Id":399917,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"42794004610"},{"Id":399918,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"42794005108"},{"Id":399919,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"42794005208"},{"Id":399920,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000110","GenericName":"ACITRETIN CAP 10 MG","NDC":"42794008008"},{"Id":399921,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 17.5MG","DosageForm":"CAPS - Capsule","Strength":"17.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000115","GenericName":"ACITRETIN CAP 17.5 MG","NDC":"42794008108"},{"Id":399922,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000125","GenericName":"ACITRETIN CAP 25 MG","NDC":"42794008308"},{"Id":399923,"FormularyType":"OHP","DrugName":"LIOMNY TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"42794013112"},{"Id":399924,"FormularyType":"OHP","DrugName":"LIOMNY TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"42794013212"},{"Id":399925,"FormularyType":"OHP","DrugName":"LIOMNY TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"42794013312"},{"Id":399926,"FormularyType":"OHP","DrugName":"ALBENDAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000002000320","GenericName":"ALBENDAZOLE TAB 200 MG","NDC":"42799011002"},{"Id":399927,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000310","GenericName":"ETODOLAC TAB 400 MG","NDC":"42799011101"},{"Id":399928,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000320","GenericName":"ETODOLAC TAB 500 MG","NDC":"42799011201"},{"Id":399929,"FormularyType":"OHP","DrugName":"COLESTIPOL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020100320","GenericName":"COLESTIPOL HCL TAB 1 GM","NDC":"42799011501"},{"Id":399930,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"42799011901"},{"Id":399931,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"42799012001"},{"Id":399932,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"42799012002"},{"Id":399933,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"42799012101"},{"Id":399934,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"42799012102"},{"Id":399935,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"42799060501"},{"Id":399936,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"42799060502"},{"Id":399937,"FormularyType":"OHP","DrugName":"IVERMECTIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000007000310","GenericName":"IVERMECTIN TAB 3 MG","NDC":"42799080601"},{"Id":399938,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202020","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)","NDC":"42799081501"},{"Id":399939,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"42799092001"},{"Id":399940,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"42799092002"},{"Id":399941,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"42799092030"},{"Id":399942,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"42799092101"},{"Id":399943,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"42799092102"},{"Id":399944,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"42799092130"},{"Id":399945,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"42799092201"},{"Id":399946,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"42799092202"},{"Id":399947,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"42799092230"},{"Id":399948,"FormularyType":"OHP","DrugName":"VIGABATRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085000320","GenericName":"VIGABATRIN TAB 500 MG","NDC":"42799095001"},{"Id":399949,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007207530","GenericName":"DICLOFENAC SODIUM TAB ER 24HR 100 MG","NDC":"42799095301"},{"Id":399950,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"42799095801"},{"Id":399951,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"42799095802"},{"Id":399952,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"42799095901"},{"Id":399953,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"42799095902"},{"Id":399954,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 120MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007540","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG","NDC":"42799096001"},{"Id":399955,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"42806000501"},{"Id":399956,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"42806000601"},{"Id":399957,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"42806000701"},{"Id":399958,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"42806000801"},{"Id":399959,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"42806000901"},{"Id":399960,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"42806001101"},{"Id":399961,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"42806001105"},{"Id":399962,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"42806001394"},{"Id":399963,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"42806001396"},{"Id":399964,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"42806001801"},{"Id":399965,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"42806001805"},{"Id":399966,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"42806004801"},{"Id":399967,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"42806005505"},{"Id":399968,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"42806005509"},{"Id":399969,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"42806005510"},{"Id":399970,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"42806005605"},{"Id":399971,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"42806005609"},{"Id":399972,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"42806005610"},{"Id":399973,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"42806005705"},{"Id":399974,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"42806005709"},{"Id":399975,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"42806005710"},{"Id":399976,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000303","GenericName":"ESTRADIOL TAB 0.5 MG","NDC":"42806008701"},{"Id":399977,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000303","GenericName":"ESTRADIOL TAB 0.5 MG","NDC":"42806008705"},{"Id":399978,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"42806008801"},{"Id":399979,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"42806008805"},{"Id":399980,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"42806008901"},{"Id":399981,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"42806008905"},{"Id":399982,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100305","GenericName":"ETHAMBUTOL HCL TAB 100 MG","NDC":"42806010101"},{"Id":399983,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100310","GenericName":"ETHAMBUTOL HCL TAB 400 MG","NDC":"42806010201"},{"Id":399984,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120310","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 80 MG","NDC":"42806012101"},{"Id":399985,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120315","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 120 MG","NDC":"42806012201"},{"Id":399986,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120320","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 160 MG","NDC":"42806012301"},{"Id":399987,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"42806013321"},{"Id":399988,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"42806013324"},{"Id":399989,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100335","GenericName":"LEUCOVORIN CALCIUM TAB 15 MG","NDC":"42806013424"},{"Id":399990,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"42806014731"},{"Id":399991,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"42806014932"},{"Id":399992,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"42806015033"},{"Id":399993,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"42806015134"},{"Id":399994,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"42806015901"},{"Id":399995,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"42806015905"},{"Id":399996,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"42806015910"},{"Id":399997,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"42806016001"},{"Id":399998,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"42806016005"},{"Id":399999,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"42806016010"},{"Id":400000,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"42806016101"},{"Id":400001,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"42806016105"},{"Id":400002,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"42806016110"},{"Id":400003,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"42806017815"},{"Id":400004,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"42806017830"},{"Id":400005,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"42806017860"},{"Id":400006,"FormularyType":"OHP","DrugName":"KLAYESTA POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"42806018615"},{"Id":400007,"FormularyType":"OHP","DrugName":"KLAYESTA POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"42806018630"},{"Id":400008,"FormularyType":"OHP","DrugName":"KLAYESTA POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"42806018660"},{"Id":400009,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"42806026005"},{"Id":400010,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"42806026060"},{"Id":400011,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"42806026695"},{"Id":400012,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"42806026698"},{"Id":400013,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"42806026793"},{"Id":400014,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"42806027095"},{"Id":400015,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"42806027098"},{"Id":400016,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"42806027193"},{"Id":400017,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"42806027401"},{"Id":400018,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"42806027501"},{"Id":400019,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"42806027601"},{"Id":400020,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"42806029601"},{"Id":400021,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"42806031005"},{"Id":400022,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"42806031050"},{"Id":400023,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"42806031205"},{"Id":400024,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"42806031250"},{"Id":400025,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"42806031305"},{"Id":400026,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"42806031401"},{"Id":400027,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"42806031505"},{"Id":400028,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"42806033901"},{"Id":400029,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"42806034101"},{"Id":400030,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"42806034301"},{"Id":400031,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"42806034401"},{"Id":400032,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"42806034501"},{"Id":400033,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"42806035801"},{"Id":400034,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"42806035830"},{"Id":400035,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100345","GenericName":"LEUCOVORIN CALCIUM TAB 25 MG","NDC":"42806035925"},{"Id":400036,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100302","GenericName":"DOXYCYCLINE HYCLATE TAB 20 MG","NDC":"42806036201"},{"Id":400037,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"42806040001"},{"Id":400038,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210003000B705","GenericName":"METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","NDC":"42806040021"},{"Id":400039,"FormularyType":"OHP","DrugName":"BUPROPION TAB 150MG SR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100002107430","GenericName":"BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG","NDC":"42806041360"},{"Id":400040,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"42806042201"},{"Id":400041,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"42806042205"},{"Id":400042,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"42806042210"},{"Id":400043,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"42806042301"},{"Id":400044,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"42806042305"},{"Id":400045,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"42806042310"},{"Id":400046,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"42806050301"},{"Id":400047,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42806050901"},{"Id":400048,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"42806050910"},{"Id":400049,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42806051001"},{"Id":400050,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"42806051010"},{"Id":400051,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42806051101"},{"Id":400052,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"42806051110"},{"Id":400053,"FormularyType":"OHP","DrugName":"QUINIDINE SU TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100030300315","GenericName":"QUINIDINE SULFATE TAB 300 MG","NDC":"42806051230"},{"Id":400054,"FormularyType":"OHP","DrugName":"QUINIDINE SU TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100030300310","GenericName":"QUINIDINE SULFATE TAB 200 MG","NDC":"42806051330"},{"Id":400055,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"42806054701"},{"Id":400056,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"42806054705"},{"Id":400057,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"42806054909"},{"Id":400058,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"42806054930"},{"Id":400059,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"42806055501"},{"Id":400060,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"42806056012"},{"Id":400061,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"42806060022"},{"Id":400062,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"42806063201"},{"Id":400063,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"42806063205"},{"Id":400064,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"42806063301"},{"Id":400065,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"42806064801"},{"Id":400066,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"42806064810"},{"Id":400067,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"42806064901"},{"Id":400068,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"42806064910"},{"Id":400069,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"42806065830"},{"Id":400070,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"42806065930"},{"Id":400071,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010000105","GenericName":"ETHOSUXIMIDE CAP 250 MG","NDC":"42806070801"},{"Id":400072,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"42806071401"},{"Id":400073,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"42806071405"},{"Id":400074,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"42806071501"},{"Id":400075,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"42806071505"},{"Id":400076,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"42806072101"},{"Id":400077,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"42806072105"},{"Id":400078,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"42806072201"},{"Id":400079,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"42806072205"},{"Id":400080,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"42806072401"},{"Id":400081,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"42806072405"},{"Id":400082,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"42806072410"},{"Id":400083,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"42806072501"},{"Id":400084,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"42806072505"},{"Id":400085,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"42806072510"},{"Id":400086,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"42806072601"},{"Id":400087,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"42806072605"},{"Id":400088,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"42806072610"},{"Id":400089,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"42806072701"},{"Id":400090,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"42806072705"},{"Id":400091,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"42806072710"},{"Id":400092,"FormularyType":"OHP","DrugName":"SULFADIAZINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"SULFONAMIDES","DrugSubClass":"SULFONAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"08000020000305","GenericName":"SULFADIAZINE TAB 500 MG","NDC":"42806075760"},{"Id":400093,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"42806079901"},{"Id":400094,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"42806079930"},{"Id":400095,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"42806079960"},{"Id":400096,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000105","GenericName":"RIFAMPIN CAP 150 MG","NDC":"42806080101"},{"Id":400097,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000105","GenericName":"RIFAMPIN CAP 150 MG","NDC":"42806080130"},{"Id":400098,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"42806081701"},{"Id":400099,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"42806081801"},{"Id":400100,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"42806081901"},{"Id":400101,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"42858000101"},{"Id":400102,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"42858000110"},{"Id":400103,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"42858000201"},{"Id":400104,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"42858000210"},{"Id":400105,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"42858000301"},{"Id":400106,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"42858000401"},{"Id":400107,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"42858000501"},{"Id":400108,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"42858005501"},{"Id":400109,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"42858006701"},{"Id":400110,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"42858010201"},{"Id":400111,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"42858010250"},{"Id":400112,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"42858010301"},{"Id":400113,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"42858010350"},{"Id":400114,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"42858010401"},{"Id":400115,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"42858010450"},{"Id":400116,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"42858013401"},{"Id":400117,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"42858016101"},{"Id":400118,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"42858016201"},{"Id":400119,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"42858016301"},{"Id":400120,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"42858016401"},{"Id":400121,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"42858016501"},{"Id":400122,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"42858016601"},{"Id":400123,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"42858016701"},{"Id":400124,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"42858020001"},{"Id":400125,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"42858020101"},{"Id":400126,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"42858020150"},{"Id":400127,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"42858020201"},{"Id":400128,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"42858020301"},{"Id":400129,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"42858020350"},{"Id":400130,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"42858021501"},{"Id":400131,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"42858032501"},{"Id":400132,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 7.5/HR","DosageForm":"PTWK - Patch Weekly","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008825","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 7.5 MCG/HR","NDC":"42858035340"},{"Id":400133,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"42858045445"},{"Id":400134,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"42858049340"},{"Id":400135,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"42858050103"},{"Id":400136,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"42858050203"},{"Id":400137,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"42858058640"},{"Id":400138,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"42858060103"},{"Id":400139,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"42858060203"},{"Id":400140,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"42858061001"},{"Id":400141,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"42858066045"},{"Id":400142,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 400MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007540","GenericName":"THEOPHYLLINE TAB ER 24HR 400 MG","NDC":"42858070101"},{"Id":400143,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"42858072001"},{"Id":400144,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"42858072101"},{"Id":400145,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"42858072201"},{"Id":400146,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"42858072301"},{"Id":400147,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"42858072401"},{"Id":400148,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"42858072501"},{"Id":400149,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"42858072601"},{"Id":400150,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"42858072701"},{"Id":400151,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"42858075040"},{"Id":400152,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"42858080101"},{"Id":400153,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"42858080201"},{"Id":400154,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"42858080301"},{"Id":400155,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"42858080401"},{"Id":400156,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 200MG ER","DosageForm":"TBCR - Tablet ER","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100480","GenericName":"MORPHINE SULFATE TAB ER 200 MG","NDC":"42858080501"},{"Id":400157,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"42858083940"},{"Id":400158,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000110","GenericName":"DRONABINOL CAP 2.5 MG","NDC":"42858086706"},{"Id":400159,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000115","GenericName":"DRONABINOL CAP 5 MG","NDC":"42858086806"},{"Id":400160,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000120","GenericName":"DRONABINOL CAP 10 MG","NDC":"42858086906"},{"Id":400161,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"42858093001"},{"Id":400162,"FormularyType":"OHP","DrugName":"PRENATAL 19 CHW 29-1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000530","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***","NDC":"42937070716"},{"Id":400163,"FormularyType":"OHP","DrugName":"PRENATAL 19 CHW 29-1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000530","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***","NDC":"42937070718"},{"Id":400164,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000505","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***","NDC":"42937070810"},{"Id":400165,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000510","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***","NDC":"42937070910"},{"Id":400166,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000520","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","NDC":"42937071010"},{"Id":400167,"FormularyType":"OHP","DrugName":"KOSHR PRENAT TAB 30-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512010000331","GenericName":"*PRENATAL VIT W/ IRON CARBONYL-FA TAB 30-1 MG***","NDC":"42937071530"},{"Id":400168,"FormularyType":"OHP","DrugName":"KOSHR PRENAT TAB 30-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512010000331","GenericName":"*PRENATAL VIT W/ IRON CARBONYL-FA TAB 30-1 MG***","NDC":"42937071560"},{"Id":400169,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"43066003101"},{"Id":400170,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"43066003125"},{"Id":400171,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"43066003501"},{"Id":400172,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"43066003505"},{"Id":400173,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"43066014201"},{"Id":400174,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"43066014210"},{"Id":400175,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"43066099324"},{"Id":400176,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"43066099524"},{"Id":400177,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"43292012345"},{"Id":400178,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"43292012349"},{"Id":400179,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"43292012354"},{"Id":400180,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"43292012356"},{"Id":400181,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000310","GenericName":"NIACINAMIDE TAB 100 MG","NDC":"43292012357"},{"Id":400182,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG TR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"43292022328"},{"Id":400183,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000360","GenericName":"POTASSIUM GLUCONATE TAB 550 MG (92 MG EQUIV K)","NDC":"43292040123"},{"Id":400184,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000360","GenericName":"POTASSIUM GLUCONATE TAB 550 MG (92 MG EQUIV K)","NDC":"43292040124"},{"Id":400185,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"43292050026"},{"Id":400186,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292050653"},{"Id":400187,"FormularyType":"OHP","DrugName":"B-COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"43292055500"},{"Id":400188,"FormularyType":"OHP","DrugName":"FRUITY CHEWS CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"43292055506"},{"Id":400189,"FormularyType":"OHP","DrugName":"FRUITY CHEWS CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"43292055507"},{"Id":400190,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000315","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG***","NDC":"43292055515"},{"Id":400191,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"43292055526"},{"Id":400192,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"43292055532"},{"Id":400193,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630345","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 500 MG-5 MCG (200 UNIT)","NDC":"43292055535"},{"Id":400194,"FormularyType":"OHP","DrugName":"NIACIN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000320","GenericName":"NIACIN TAB 50 MG","NDC":"43292055539"},{"Id":400195,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"43292055565"},{"Id":400196,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"43292055566"},{"Id":400197,"FormularyType":"OHP","DrugName":"BETTER B TAB COMPLEX","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"43292055570"},{"Id":400198,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"43292055581"},{"Id":400199,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630365","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 600 MG-5 MCG (200 UNIT)","NDC":"43292055585"},{"Id":400200,"FormularyType":"OHP","DrugName":"TRI-BUFF ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64109902040320","GenericName":"ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG","NDC":"43292055588"},{"Id":400201,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"43292055589"},{"Id":400202,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"43292055591"},{"Id":400203,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"43292055592"},{"Id":400204,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"43292055595"},{"Id":400205,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"43292055601"},{"Id":400206,"FormularyType":"OHP","DrugName":"DSS CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"43292055603"},{"Id":400207,"FormularyType":"OHP","DrugName":"DSS CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"43292055604"},{"Id":400208,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"43292055606"},{"Id":400209,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"43292055611"},{"Id":400210,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"43292055612"},{"Id":400211,"FormularyType":"OHP","DrugName":"TRI-BUFF ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64109902040320","GenericName":"ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG","NDC":"43292055614"},{"Id":400212,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"43292055615"},{"Id":400213,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292055617"},{"Id":400214,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"43292055618"},{"Id":400215,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"43292055621"},{"Id":400216,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"43292055622"},{"Id":400217,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292055625"},{"Id":400218,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292055626"},{"Id":400219,"FormularyType":"OHP","DrugName":"CHLORHIST TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"43292055628"},{"Id":400220,"FormularyType":"OHP","DrugName":"ALERTAB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"43292055631"},{"Id":400221,"FormularyType":"OHP","DrugName":"EXTRAPRIN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"43292055635"},{"Id":400222,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"43292055636"},{"Id":400223,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"43292055637"},{"Id":400224,"FormularyType":"OHP","DrugName":"CALCIUM 600/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"43292055643"},{"Id":400225,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000315","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG***","NDC":"43292055670"},{"Id":400226,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"43292055686"},{"Id":400227,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB","DosageForm":"TABS - Tablet","Strength":"1500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"43292055694"},{"Id":400228,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292055700"},{"Id":400229,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG TR","DosageForm":"TBCR - Tablet ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000440","GenericName":"NIACIN TAB ER 250 MG","NDC":"43292055703"},{"Id":400230,"FormularyType":"OHP","DrugName":"ALER-CAP CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"43292055705"},{"Id":400231,"FormularyType":"OHP","DrugName":"TRAV-TABS TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"43292055712"},{"Id":400232,"FormularyType":"OHP","DrugName":"SLEEP-TABS TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"43292055719"},{"Id":400233,"FormularyType":"OHP","DrugName":"PAIN RELIEVR CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"43292055737"},{"Id":400234,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000340","GenericName":"NIACIN TAB 250 MG","NDC":"43292055740"},{"Id":400235,"FormularyType":"OHP","DrugName":"PRENATAL TAB FORTE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000315","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG***","NDC":"43292055755"},{"Id":400236,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100310","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 50 MG","NDC":"43292055765"},{"Id":400237,"FormularyType":"OHP","DrugName":"SLEEP-TABS TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"43292055778"},{"Id":400238,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"43292055792"},{"Id":400239,"FormularyType":"OHP","DrugName":"PAIN RELIEVR CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"43292055793"},{"Id":400240,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"43292055881"},{"Id":400241,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"43292055910"},{"Id":400242,"FormularyType":"OHP","DrugName":"VITAMIN B-12 SUB 1000MCG","DosageForm":"SUBL - Tab Sublingual","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000705","GenericName":"CYANOCOBALAMIN SL TAB 1000 MCG","NDC":"43292055992"},{"Id":400243,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"43292055995"},{"Id":400244,"FormularyType":"OHP","DrugName":"B COMPLEX/C TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"43292056011"},{"Id":400245,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"43292056012"},{"Id":400246,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"43292056016"},{"Id":400247,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"43292056017"},{"Id":400248,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292056054"},{"Id":400249,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292056055"},{"Id":400250,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"43292056083"},{"Id":400251,"FormularyType":"OHP","DrugName":"COMP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"43292056179"},{"Id":400252,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"43292056206"},{"Id":400253,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"43292056229"},{"Id":400254,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"43292056286"},{"Id":400255,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"43292056294"},{"Id":400256,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"43292056298"},{"Id":400257,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"43292056299"},{"Id":400258,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"43292056329"},{"Id":400259,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1250MCG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"43292056336"},{"Id":400260,"FormularyType":"OHP","DrugName":"EXTRAPRIN TAB EX STR","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"43292056337"},{"Id":400261,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"43292056338"},{"Id":400262,"FormularyType":"OHP","DrugName":"EXTRAPRIN TAB EX STR","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"43292056340"},{"Id":400263,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"43292056358"},{"Id":400264,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"43292056360"},{"Id":400265,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"43292056362"},{"Id":400266,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"43292056366"},{"Id":400267,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"43292056371"},{"Id":400268,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"43292056383"},{"Id":400269,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"43292056392"},{"Id":400270,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"43292056396"},{"Id":400271,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"43292056397"},{"Id":400272,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"43292056398"},{"Id":400273,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"43292056405"},{"Id":400274,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"43292056414"},{"Id":400275,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"43292056428"},{"Id":400276,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"43292056429"},{"Id":400277,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"43292056434"},{"Id":400278,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292056447"},{"Id":400279,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"43292056450"},{"Id":400280,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"43292056505"},{"Id":400281,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"43292056512"},{"Id":400282,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"43292056523"},{"Id":400283,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"43292056525"},{"Id":400284,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100310","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 50 MG","NDC":"43292056765"},{"Id":400285,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"43292090206"},{"Id":400286,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"43386002602"},{"Id":400287,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"43386002606"},{"Id":400288,"FormularyType":"OHP","DrugName":"VORICONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407080001920","GenericName":"VORICONAZOLE FOR SUSP 40 MG/ML","NDC":"43386003860"},{"Id":400289,"FormularyType":"OHP","DrugName":"GAVILYTE-N SOL FLAV PK","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992004302120","GenericName":"PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM","NDC":"43386005019"},{"Id":400290,"FormularyType":"OHP","DrugName":"GAVILYTE-C SOL","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992005302140","GenericName":"PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM","NDC":"43386006019"},{"Id":400291,"FormularyType":"OHP","DrugName":"FLUOCINOLONE SOL 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550055102005","GenericName":"FLUOCINOLONE ACETONIDE SOLN 0.01%","NDC":"43386006960"},{"Id":400292,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"43386008803"},{"Id":400293,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"43386008903"},{"Id":400294,"FormularyType":"OHP","DrugName":"GAVILYTE-G SOL","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992005302130","GenericName":"PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM","NDC":"43386009019"},{"Id":400295,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"43386009660"},{"Id":400296,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"43386009661"},{"Id":400297,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"43386009662"},{"Id":400298,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"43386009663"},{"Id":400299,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 10MG","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004040","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG","NDC":"43386028001"},{"Id":400300,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 20MG","DosageForm":"GEL - Gel","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004060","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG","NDC":"43386028101"},{"Id":400301,"FormularyType":"OHP","DrugName":"GAVILAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"43386031208"},{"Id":400302,"FormularyType":"OHP","DrugName":"GAVILAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"43386031214"},{"Id":400303,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"43386035605"},{"Id":400304,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"43386035705"},{"Id":400305,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"43386035710"},{"Id":400306,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"43386035805"},{"Id":400307,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"43386047060"},{"Id":400308,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"43386047161"},{"Id":400309,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"43386050011"},{"Id":400310,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"43386054001"},{"Id":400311,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"43386054101"},{"Id":400312,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"43386054201"},{"Id":400313,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"43386054301"},{"Id":400314,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 200MG ER","DosageForm":"TBCR - Tablet ER","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100480","GenericName":"MORPHINE SULFATE TAB ER 200 MG","NDC":"43386054401"},{"Id":400315,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"43386064101"},{"Id":400316,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"43386064201"},{"Id":400317,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000110","GenericName":"FLUCYTOSINE CAP 500 MG","NDC":"43386077001"},{"Id":400318,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000105","GenericName":"FLUCYTOSINE CAP 250 MG","NDC":"43386077101"},{"Id":400319,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000105","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 50 MG","NDC":"43386079001"},{"Id":400320,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"43386079202"},{"Id":400321,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"43386079211"},{"Id":400322,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"43386079401"},{"Id":400323,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"43386079405"},{"Id":400324,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"43386079450"},{"Id":400325,"FormularyType":"OHP","DrugName":"MIFEPRISTONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROGESTERONE RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30502060000320","GenericName":"MIFEPRISTONE TAB 200 MG","NDC":"43393000101"},{"Id":400326,"FormularyType":"OHP","DrugName":"MIFEPRISTONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROGESTERONE RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30502060000320","GenericName":"MIFEPRISTONE TAB 200 MG","NDC":"43393000106"},{"Id":400327,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"43393002404"},{"Id":400328,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"43393020004"},{"Id":400329,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"43393020048"},{"Id":400330,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"43393020060"},{"Id":400331,"FormularyType":"OHP","DrugName":"HEPLISAV-B INJ 20/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001030E520","GenericName":"HEPATITIS B VACCINE RECOMB ADJUVANTED PREF SYR 20 MCG/0.5ML","NDC":"43528000301"},{"Id":400332,"FormularyType":"OHP","DrugName":"HEPLISAV-B INJ 20/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001030E520","GenericName":"HEPATITIS B VACCINE RECOMB ADJUVANTED PREF SYR 20 MCG/0.5ML","NDC":"43528000305"},{"Id":400333,"FormularyType":"OHP","DrugName":"CICLODAN SOL 8%","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030002020","GenericName":"CICLOPIROX SOLUTION 8%","NDC":"43538050006"},{"Id":400334,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"43538080501"},{"Id":400335,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"43538080510"},{"Id":400336,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"43538081001"},{"Id":400337,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"43538081010"},{"Id":400338,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43547000103"},{"Id":400339,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"43547000203"},{"Id":400340,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"43547000209"},{"Id":400341,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"43547000211"},{"Id":400342,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"43547000503"},{"Id":400343,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"43547000509"},{"Id":400344,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"43547002414"},{"Id":400345,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"43547002506"},{"Id":400346,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"43547022115"},{"Id":400347,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"43547022215"},{"Id":400348,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"43547022250"},{"Id":400349,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"43547022315"},{"Id":400350,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"43547022406"},{"Id":400351,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"43547022610"},{"Id":400352,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"43547022650"},{"Id":400353,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"43547026810"},{"Id":400354,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"43547026850"},{"Id":400355,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"43547026910"},{"Id":400356,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"43547026950"},{"Id":400357,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"43547027010"},{"Id":400358,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"43547027050"},{"Id":400359,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"43547027110"},{"Id":400360,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"43547027150"},{"Id":400361,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100337","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 3 MG","NDC":"43547027210"},{"Id":400362,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100344","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 4 MG","NDC":"43547027310"},{"Id":400363,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100350","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 5 MG","NDC":"43547027410"},{"Id":400364,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"43547027503"},{"Id":400365,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"43547027509"},{"Id":400366,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"43547027511"},{"Id":400367,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"43547027603"},{"Id":400368,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"43547027609"},{"Id":400369,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"43547027611"},{"Id":400370,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"43547028303"},{"Id":400371,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"43547028403"},{"Id":400372,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"43547028503"},{"Id":400373,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"43547029503"},{"Id":400374,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"43547029603"},{"Id":400375,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"43547029903"},{"Id":400376,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"43547030003"},{"Id":400377,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"43547030009"},{"Id":400378,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"43547030103"},{"Id":400379,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"43547030109"},{"Id":400380,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"43547031109"},{"Id":400381,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"43547031209"},{"Id":400382,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"43547031309"},{"Id":400383,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"43547031409"},{"Id":400384,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"43547031509"},{"Id":400385,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"43547033003"},{"Id":400386,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"43547033009"},{"Id":400387,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"43547033103"},{"Id":400388,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"43547033109"},{"Id":400389,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"43547033510"},{"Id":400390,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"43547033610"},{"Id":400391,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"43547033650"},{"Id":400392,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"43547033703"},{"Id":400393,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"43547033710"},{"Id":400394,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"43547033750"},{"Id":400395,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"43547033803"},{"Id":400396,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"43547033810"},{"Id":400397,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"43547033850"},{"Id":400398,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007520","GenericName":"LEVETIRACETAM TAB ER 24HR 500 MG","NDC":"43547034506"},{"Id":400399,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"43547034606"},{"Id":400400,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"43547035110"},{"Id":400401,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"43547035150"},{"Id":400402,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"43547035210"},{"Id":400403,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"43547035211"},{"Id":400404,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"43547035310"},{"Id":400405,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"43547035311"},{"Id":400406,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"43547035410"},{"Id":400407,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"43547035411"},{"Id":400408,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"43547035510"},{"Id":400409,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"43547035550"},{"Id":400410,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"43547035610"},{"Id":400411,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"43547035611"},{"Id":400412,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"43547036009"},{"Id":400413,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"43547036011"},{"Id":400414,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"43547036103"},{"Id":400415,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"43547036109"},{"Id":400416,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"43547036111"},{"Id":400417,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"43547036203"},{"Id":400418,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"43547036209"},{"Id":400419,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"43547036211"},{"Id":400420,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"43547036310"},{"Id":400421,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"43547036410"},{"Id":400422,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"43547036510"},{"Id":400423,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"43547036610"},{"Id":400424,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"43547036703"},{"Id":400425,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"43547036709"},{"Id":400426,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"43547036809"},{"Id":400427,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"43547036909"},{"Id":400428,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"43547037009"},{"Id":400429,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"43547037403"},{"Id":400430,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"43547037409"},{"Id":400431,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"43547037450"},{"Id":400432,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"43547037503"},{"Id":400433,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"43547037509"},{"Id":400434,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"43547037550"},{"Id":400435,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"43547037603"},{"Id":400436,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"43547037609"},{"Id":400437,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"43547037650"},{"Id":400438,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"43547037703"},{"Id":400439,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"43547037803"},{"Id":400440,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"43547038609"},{"Id":400441,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"43547038611"},{"Id":400442,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"43547038709"},{"Id":400443,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"43547038711"},{"Id":400444,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"43547038809"},{"Id":400445,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"43547038811"},{"Id":400446,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"43547039103"},{"Id":400447,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"43547039109"},{"Id":400448,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"43547039203"},{"Id":400449,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"43547039209"},{"Id":400450,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"43547039303"},{"Id":400451,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"43547039309"},{"Id":400452,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"43547039410"},{"Id":400453,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"43547039450"},{"Id":400454,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"43547039510"},{"Id":400455,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"43547039550"},{"Id":400456,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"43547039610"},{"Id":400457,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"43547039650"},{"Id":400458,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"43547039710"},{"Id":400459,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"43547039711"},{"Id":400460,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"43547039810"},{"Id":400461,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"43547039811"},{"Id":400462,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"43547039910"},{"Id":400463,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"43547039950"},{"Id":400464,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"43547040010"},{"Id":400465,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"43547040011"},{"Id":400466,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"43547040050"},{"Id":400467,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"43547040110"},{"Id":400468,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"43547040111"},{"Id":400469,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"43547040210"},{"Id":400470,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"43547040211"},{"Id":400471,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"43547040310"},{"Id":400472,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"43547040350"},{"Id":400473,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"43547040510"},{"Id":400474,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"43547040550"},{"Id":400475,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"43547040610"},{"Id":400476,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"43547040611"},{"Id":400477,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"43547040650"},{"Id":400478,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"43547040710"},{"Id":400479,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"43547040711"},{"Id":400480,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"43547040750"},{"Id":400481,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"43547040810"},{"Id":400482,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"43547040850"},{"Id":400483,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"43547041450"},{"Id":400484,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"43547041511"},{"Id":400485,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"43547041611"},{"Id":400486,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"43547041711"},{"Id":400487,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"43547041850"},{"Id":400488,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"43547041911"},{"Id":400489,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"43547042010"},{"Id":400490,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"43547042050"},{"Id":400491,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"43547042110"},{"Id":400492,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"43547042150"},{"Id":400493,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"43547042210"},{"Id":400494,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"43547042250"},{"Id":400495,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"43547042303"},{"Id":400496,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"43547042309"},{"Id":400497,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"43547042311"},{"Id":400498,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"43547042403"},{"Id":400499,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"43547042409"},{"Id":400500,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"43547042411"},{"Id":400501,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"43547042503"},{"Id":400502,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"43547042509"},{"Id":400503,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"43547042511"},{"Id":400504,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"43547042603"},{"Id":400505,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"43547042609"},{"Id":400506,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"43547042650"},{"Id":400507,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"43547042703"},{"Id":400508,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"43547042709"},{"Id":400509,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"43547042750"},{"Id":400510,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"43547042803"},{"Id":400511,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"43547042809"},{"Id":400512,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"43547042850"},{"Id":400513,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"43547043009"},{"Id":400514,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"43547043109"},{"Id":400515,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"43547043603"},{"Id":400516,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"43547043703"},{"Id":400517,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 16-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200320","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG","NDC":"43547045909"},{"Id":400518,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200340","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG","NDC":"43547046009"},{"Id":400519,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200350","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-25 MG","NDC":"43547046109"},{"Id":400520,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"43547048610"},{"Id":400521,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"43547048710"},{"Id":400522,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"43547048810"},{"Id":400523,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"43547050609"},{"Id":400524,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"43547050709"},{"Id":400525,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"43547050809"},{"Id":400526,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"43547050909"},{"Id":400527,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"43547051009"},{"Id":400528,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"43547051109"},{"Id":400529,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"43547051209"},{"Id":400530,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"43547051309"},{"Id":400531,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"43547054510"},{"Id":400532,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"43547054511"},{"Id":400533,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"43547054610"},{"Id":400534,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"43547054611"},{"Id":400535,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"43547054710"},{"Id":400536,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"43547054711"},{"Id":400537,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"43547054810"},{"Id":400538,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"43547054811"},{"Id":400539,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 8MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000205","GenericName":"POTASSIUM CHLORIDE CAP ER 8 MEQ","NDC":"43547055210"},{"Id":400540,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"43547055310"},{"Id":400541,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"43547055350"},{"Id":400542,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"43547056510"},{"Id":400543,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"43547056511"},{"Id":400544,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"43547056610"},{"Id":400545,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"43547056611"},{"Id":400546,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"43547056710"},{"Id":400547,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"43547059510"},{"Id":400548,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"43547059610"},{"Id":400549,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"43547059710"},{"Id":400550,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"43547059810"},{"Id":400551,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100337","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 3 MG","NDC":"43547059910"},{"Id":400552,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100344","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 4 MG","NDC":"43547060010"},{"Id":400553,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100350","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 5 MG","NDC":"43547060110"},{"Id":400554,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"43547060210"},{"Id":400555,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"43547060310"},{"Id":400556,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"43547060410"},{"Id":400557,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"43547060510"},{"Id":400558,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"43547060610"},{"Id":400559,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"43547060710"},{"Id":400560,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"43547060810"},{"Id":400561,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"43547061603"},{"Id":400562,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"43547061610"},{"Id":400563,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"43547061703"},{"Id":400564,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"43547061710"},{"Id":400565,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"43547063410"},{"Id":400566,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"43547063411"},{"Id":400567,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"43547068810"},{"Id":400568,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"43547068910"},{"Id":400569,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"43547068950"},{"Id":400570,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"43547089610"},{"Id":400571,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"43547089710"},{"Id":400572,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"43547089750"},{"Id":400573,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"43547089810"},{"Id":400574,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"43547089850"},{"Id":400575,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"43547098510"},{"Id":400576,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"43547098604"},{"Id":400577,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"43547098610"},{"Id":400578,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"43547098710"},{"Id":400579,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"43547099006"},{"Id":400580,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"43598002353"},{"Id":400581,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"43598004563"},{"Id":400582,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"43598004663"},{"Id":400583,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"43598004763"},{"Id":400584,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"43598004863"},{"Id":400585,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 40/10ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"43598005311"},{"Id":400586,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"43598008711"},{"Id":400587,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"43598008758"},{"Id":400588,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"43598009805"},{"Id":400589,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"43598009890"},{"Id":400590,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"43598009905"},{"Id":400591,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"43598009990"},{"Id":400592,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"43598010105"},{"Id":400593,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"43598010190"},{"Id":400594,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"43598010305"},{"Id":400595,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"43598010390"},{"Id":400596,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"43598012105"},{"Id":400597,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"43598012130"},{"Id":400598,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"43598012190"},{"Id":400599,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"43598012725"},{"Id":400600,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"43598012745"},{"Id":400601,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"43598016001"},{"Id":400602,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"43598016053"},{"Id":400603,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"43598016701"},{"Id":400604,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"43598016710"},{"Id":400605,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"43598017001"},{"Id":400606,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"43598017010"},{"Id":400607,"FormularyType":"OHP","DrugName":"SSD CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"43598021025"},{"Id":400608,"FormularyType":"OHP","DrugName":"SSD CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"43598021040"},{"Id":400609,"FormularyType":"OHP","DrugName":"SSD CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"43598021050"},{"Id":400610,"FormularyType":"OHP","DrugName":"SSD CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"43598021055"},{"Id":400611,"FormularyType":"OHP","DrugName":"SSD CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"43598021085"},{"Id":400612,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"43598026704"},{"Id":400613,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"43598028530"},{"Id":400614,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"43598029190"},{"Id":400615,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"43598029266"},{"Id":400616,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"43598029279"},{"Id":400617,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"43598029290"},{"Id":400618,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"43598029366"},{"Id":400619,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"43598029379"},{"Id":400620,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"43598029390"},{"Id":400621,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"43598029466"},{"Id":400622,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"43598029479"},{"Id":400623,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"43598029490"},{"Id":400624,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"43598029566"},{"Id":400625,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"43598029579"},{"Id":400626,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"43598029590"},{"Id":400627,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"43598029690"},{"Id":400628,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"43598029790"},{"Id":400629,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"43598029890"},{"Id":400630,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"43598030330"},{"Id":400631,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"43598030390"},{"Id":400632,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"43598030488"},{"Id":400633,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"43598032675"},{"Id":400634,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"43598033960"},{"Id":400635,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"43598034431"},{"Id":400636,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"43598034479"},{"Id":400637,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"43598034490"},{"Id":400638,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"43598034530"},{"Id":400639,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"43598034531"},{"Id":400640,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"43598034579"},{"Id":400641,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"43598034901"},{"Id":400642,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"43598035001"},{"Id":400643,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"43598035804"},{"Id":400644,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"43598036730"},{"Id":400645,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"43598036830"},{"Id":400646,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"43598037201"},{"Id":400647,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"43598037210"},{"Id":400648,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"43598037230"},{"Id":400649,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"43598039030"},{"Id":400650,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"43598039090"},{"Id":400651,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"43598039467"},{"Id":400652,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"43598039567"},{"Id":400653,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43598040727"},{"Id":400654,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43598040733"},{"Id":400655,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43598040752"},{"Id":400656,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"43598042952"},{"Id":400657,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"43598043060"},{"Id":400658,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"43598043501"},{"Id":400659,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"43598043601"},{"Id":400660,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"43598043611"},{"Id":400661,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"43598043635"},{"Id":400662,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"43598043701"},{"Id":400663,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"43598044001"},{"Id":400664,"FormularyType":"OHP","DrugName":"NICOTINE SYS KIT TRANSDER","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005006430","GenericName":"NICOTINE TD PATCH 24 HR KIT 21-14-7 MG/24HR","NDC":"43598044556"},{"Id":400665,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"43598044670"},{"Id":400666,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"43598044674"},{"Id":400667,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"43598044770"},{"Id":400668,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"43598044774"},{"Id":400669,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"43598044828"},{"Id":400670,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"43598044870"},{"Id":400671,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"43598044874"},{"Id":400672,"FormularyType":"OHP","DrugName":"ALBENDAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000002000320","GenericName":"ALBENDAZOLE TAB 200 MG","NDC":"43598045202"},{"Id":400673,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"43598045360"},{"Id":400674,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"43598045646"},{"Id":400675,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"43598045674"},{"Id":400676,"FormularyType":"OHP","DrugName":"SORAFENIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533060400320","GenericName":"SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"43598045804"},{"Id":400677,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"43598046860"},{"Id":400678,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"43598047060"},{"Id":400679,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"43598047801"},{"Id":400680,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"43598047890"},{"Id":400681,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"43598047901"},{"Id":400682,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"43598047990"},{"Id":400683,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"43598048610"},{"Id":400684,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"43598048624"},{"Id":400685,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"43598048627"},{"Id":400686,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"43598048672"},{"Id":400687,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"43598048681"},{"Id":400688,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"43598048724"},{"Id":400689,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"43598048727"},{"Id":400690,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"43598048772"},{"Id":400691,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"43598048781"},{"Id":400692,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"43598050501"},{"Id":400693,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"43598050510"},{"Id":400694,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"43598050530"},{"Id":400695,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43598050910"},{"Id":400696,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43598050930"},{"Id":400697,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"43598050990"},{"Id":400698,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"43598051010"},{"Id":400699,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"43598051030"},{"Id":400700,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"43598051090"},{"Id":400701,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"43598051163"},{"Id":400702,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"43598051263"},{"Id":400703,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"43598051321"},{"Id":400704,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"43598051421"},{"Id":400705,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"43598051521"},{"Id":400706,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"43598051663"},{"Id":400707,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"43598054601"},{"Id":400708,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"43598054605"},{"Id":400709,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"43598054701"},{"Id":400710,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"43598054705"},{"Id":400711,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"43598057860"},{"Id":400712,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"43598057901"},{"Id":400713,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"43598057930"},{"Id":400714,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"43598058001"},{"Id":400715,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"43598058030"},{"Id":400716,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"43598058101"},{"Id":400717,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"43598058130"},{"Id":400718,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"43598058201"},{"Id":400719,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"43598058230"},{"Id":400720,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"43598059960"},{"Id":400721,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"43598060060"},{"Id":400722,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"43598060160"},{"Id":400723,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"43598060230"},{"Id":400724,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"43598060330"},{"Id":400725,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"43598060430"},{"Id":400726,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"43598060504"},{"Id":400727,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"43598060511"},{"Id":400728,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"43598060556"},{"Id":400729,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"43598060558"},{"Id":400730,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 3.75-23","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307020","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 3.75-23 MG","NDC":"43598062430"},{"Id":400731,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 7.5-46MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307030","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 7.5-46 MG","NDC":"43598062530"},{"Id":400732,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 11.25-69","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307040","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 11.25-69 MG","NDC":"43598062630"},{"Id":400733,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 15-92MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307050","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 15-92 MG","NDC":"43598062730"},{"Id":400734,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"43598064160"},{"Id":400735,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"43598064260"},{"Id":400736,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"43598064318"},{"Id":400737,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"43598064360"},{"Id":400738,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"43598064418"},{"Id":400739,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"43598064460"},{"Id":400740,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"43598064518"},{"Id":400741,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"43598064560"},{"Id":400742,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002060","GenericName":"TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML)","NDC":"43598064611"},{"Id":400743,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002070","GenericName":"TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML)","NDC":"43598064711"},{"Id":400744,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002080","GenericName":"TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML)","NDC":"43598064811"},{"Id":400745,"FormularyType":"OHP","DrugName":"TREPROSTINIL INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002050","GenericName":"TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML)","NDC":"43598064911"},{"Id":400746,"FormularyType":"OHP","DrugName":"VIGABATRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085000320","GenericName":"VIGABATRIN TAB 500 MG","NDC":"43598065101"},{"Id":400747,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 50MG5/ML","DosageForm":"SUSP - Suspension","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101805","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 10 MG/ML","NDC":"43598067611"},{"Id":400748,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 200/5ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"43598069411"},{"Id":400749,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"43598069711"},{"Id":400750,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"43598069750"},{"Id":400751,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"43598070460"},{"Id":400752,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"43598070530"},{"Id":400753,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"43598071901"},{"Id":400754,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"43598071910"},{"Id":400755,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"43598072001"},{"Id":400756,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"43598072010"},{"Id":400757,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"43598072101"},{"Id":400758,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"43598072105"},{"Id":400759,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"43598074101"},{"Id":400760,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"43598074130"},{"Id":400761,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 0.5GM","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100110","GenericName":"ICOSAPENT ETHYL CAP 0.5 GM","NDC":"43598074672"},{"Id":400762,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"43598074711"},{"Id":400763,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"43598075010"},{"Id":400764,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"43598075011"},{"Id":400765,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"43598076402"},{"Id":400766,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"43598076507"},{"Id":400767,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"43598076811"},{"Id":400768,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"43598076823"},{"Id":400769,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"43598081112"},{"Id":400770,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"43598081115"},{"Id":400771,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"43598083005"},{"Id":400772,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"43598083090"},{"Id":400773,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"43598083105"},{"Id":400774,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"43598083190"},{"Id":400775,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"43598083205"},{"Id":400776,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"43598083290"},{"Id":400777,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"43598083305"},{"Id":400778,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"43598083390"},{"Id":400779,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"43598085130"},{"Id":400780,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"43598085230"},{"Id":400781,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"43598085330"},{"Id":400782,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 500MG","DosageForm":"TBSO - Tablet Soluble","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007340","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 500 MG","NDC":"43598085430"},{"Id":400783,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 125MG","DosageForm":"TBSO - Tablet Soluble","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007320","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 125 MG","NDC":"43598085530"},{"Id":400784,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 250MG","DosageForm":"TBSO - Tablet Soluble","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007330","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 250 MG","NDC":"43598085630"},{"Id":400785,"FormularyType":"OHP","DrugName":"BUPROPION TAB 150MG SR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100002107430","GenericName":"BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG","NDC":"43598086360"},{"Id":400786,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"43598089110"},{"Id":400787,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"43598089152"},{"Id":400788,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.6MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008550","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR","NDC":"43598089330"},{"Id":400789,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.4MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008540","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR","NDC":"43598089430"},{"Id":400790,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.2MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008520","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR","NDC":"43598089530"},{"Id":400791,"FormularyType":"OHP","DrugName":"NITROGLYCER DIS 0.1MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008510","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR","NDC":"43598089630"},{"Id":400792,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"43598090111"},{"Id":400793,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"43598090158"},{"Id":400794,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"43598090756"},{"Id":400795,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"43598090856"},{"Id":400796,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"43598090990"},{"Id":400797,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"43598091005"},{"Id":400798,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"43598091090"},{"Id":400799,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"43598093109"},{"Id":400800,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"43598093111"},{"Id":400801,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"43598097710"},{"Id":400802,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"43749044000"},{"Id":400803,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"43749044025"},{"Id":400804,"FormularyType":"OHP","DrugName":"ULTILET PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"43820050100"},{"Id":400805,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900011642"},{"Id":400806,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900011721"},{"Id":400807,"FormularyType":"OHP","DrugName":"COMPLEAT ORG LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900011990"},{"Id":400808,"FormularyType":"OHP","DrugName":"BOOST LIQ BREEZE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900012801"},{"Id":400809,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900013576"},{"Id":400810,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900014010"},{"Id":400811,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900014180"},{"Id":400812,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900014240"},{"Id":400813,"FormularyType":"OHP","DrugName":"BOOST SOOTHE LIQ PCH/MINT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"43900014373"},{"Id":400814,"FormularyType":"OHP","DrugName":"RESOURCE 2.0 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900015167"},{"Id":400815,"FormularyType":"OHP","DrugName":"BOOST LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900016972"},{"Id":400816,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ STND 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900017509"},{"Id":400817,"FormularyType":"OHP","DrugName":"ISOSOURCE LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018150"},{"Id":400818,"FormularyType":"OHP","DrugName":"ISOSOURCE LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018181"},{"Id":400819,"FormularyType":"OHP","DrugName":"ISOSOURCE LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018182"},{"Id":400820,"FormularyType":"OHP","DrugName":"BOOST VHC LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018215"},{"Id":400821,"FormularyType":"OHP","DrugName":"ISOSOURCE HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018457"},{"Id":400822,"FormularyType":"OHP","DrugName":"ISOSOURCE HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018466"},{"Id":400823,"FormularyType":"OHP","DrugName":"ISOSOURCE HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018480"},{"Id":400824,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018544"},{"Id":400825,"FormularyType":"OHP","DrugName":"FIBERSOUR HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018555"},{"Id":400826,"FormularyType":"OHP","DrugName":"FIBERSOURCE LIQ HN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018582"},{"Id":400827,"FormularyType":"OHP","DrugName":"BOOST LIQ BREEZE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018629"},{"Id":400828,"FormularyType":"OHP","DrugName":"BOOST LIQ BREEZE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018649"},{"Id":400829,"FormularyType":"OHP","DrugName":"BOOST LIQ BREEZE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900018666"},{"Id":400830,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900019270"},{"Id":400831,"FormularyType":"OHP","DrugName":"ARGINAID LIQ EXTRA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900019660"},{"Id":400832,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900022872"},{"Id":400833,"FormularyType":"OHP","DrugName":"IMPACT ADV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900022910"},{"Id":400834,"FormularyType":"OHP","DrugName":"BOOST LIQ BREEZE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900023896"},{"Id":400835,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900025675"},{"Id":400836,"FormularyType":"OHP","DrugName":"BENECALORIE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900028250"},{"Id":400837,"FormularyType":"OHP","DrugName":"BOOST 1.0CAL LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900028574"},{"Id":400838,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900028680"},{"Id":400839,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900030609"},{"Id":400840,"FormularyType":"OHP","DrugName":"COMPLEAT ORG LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900032096"},{"Id":400841,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ /FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033500"},{"Id":400842,"FormularyType":"OHP","DrugName":"BOOST 1.0CAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033511"},{"Id":400843,"FormularyType":"OHP","DrugName":"BOOST 1.0CAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033520"},{"Id":400844,"FormularyType":"OHP","DrugName":"BOOST 1.0CAL LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033530"},{"Id":400845,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033540"},{"Id":400846,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033588"},{"Id":400847,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033590"},{"Id":400848,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900033871"},{"Id":400849,"FormularyType":"OHP","DrugName":"BOOST VHC LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900034470"},{"Id":400850,"FormularyType":"OHP","DrugName":"PEPTAMEN 1.5 LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900034957"},{"Id":400851,"FormularyType":"OHP","DrugName":"PEPTAMEN 1.5 LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900034958"},{"Id":400852,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900035111"},{"Id":400853,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ STND 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900035118"},{"Id":400854,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900035180"},{"Id":400855,"FormularyType":"OHP","DrugName":"IMPACT LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900035810"},{"Id":400856,"FormularyType":"OHP","DrugName":"IMPACT LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900035818"},{"Id":400857,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ PHGG 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036159"},{"Id":400858,"FormularyType":"OHP","DrugName":"VIVONEX RTF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036250"},{"Id":400859,"FormularyType":"OHP","DrugName":"VIVONEX RTF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036280"},{"Id":400860,"FormularyType":"OHP","DrugName":"DIABETISOURC LIQ AC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036500"},{"Id":400861,"FormularyType":"OHP","DrugName":"DIABETISOURC LIQ AC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036508"},{"Id":400862,"FormularyType":"OHP","DrugName":"DIABETISOURC LIQ AC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036582"},{"Id":400863,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900036922"},{"Id":400864,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ RED CALR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900038074"},{"Id":400865,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900040722"},{"Id":400866,"FormularyType":"OHP","DrugName":"BOOST BREEZE LIQ 2-FLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900042878"},{"Id":400867,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900046444"},{"Id":400868,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ HP","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900046768"},{"Id":400869,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900046908"},{"Id":400870,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900047993"},{"Id":400871,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900048211"},{"Id":400872,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ STND 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900049106"},{"Id":400873,"FormularyType":"OHP","DrugName":"BOOST SOOTHE LIQ STR/KIWI","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"43900050593"},{"Id":400874,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900050681"},{"Id":400875,"FormularyType":"OHP","DrugName":"BOOST SOOTHE LIQ PCH/MINT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"43900050924"},{"Id":400876,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ STND 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900054067"},{"Id":400877,"FormularyType":"OHP","DrugName":"ARGINAID LIQ EXTRA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900057046"},{"Id":400878,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900058028"},{"Id":400879,"FormularyType":"OHP","DrugName":"BOOST LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900058276"},{"Id":400880,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900058541"},{"Id":400881,"FormularyType":"OHP","DrugName":"BOOST HI-PRO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900064583"},{"Id":400882,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900064994"},{"Id":400883,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900065142"},{"Id":400884,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900066001"},{"Id":400885,"FormularyType":"OHP","DrugName":"BOOST GLUCOS LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900066110"},{"Id":400886,"FormularyType":"OHP","DrugName":"BOOST VHC LIQ STRWBRRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900066145"},{"Id":400887,"FormularyType":"OHP","DrugName":"BOOST 1.5CAL LIQ /FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900066328"},{"Id":400888,"FormularyType":"OHP","DrugName":"BOOST LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900067439"},{"Id":400889,"FormularyType":"OHP","DrugName":"BOOST LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900067539"},{"Id":400890,"FormularyType":"OHP","DrugName":"BOOST LIQ STRWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900067638"},{"Id":400891,"FormularyType":"OHP","DrugName":"BOOST LIQ BREEZE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900068560"},{"Id":400892,"FormularyType":"OHP","DrugName":"PEPTAMEN LIQ INTS VHP","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900072395"},{"Id":400893,"FormularyType":"OHP","DrugName":"PEPTAMEN LIQ INTS VHP","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900073049"},{"Id":400894,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ STND 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900074815"},{"Id":400895,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900075442"},{"Id":400896,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900076283"},{"Id":400897,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900076469"},{"Id":400898,"FormularyType":"OHP","DrugName":"BOOST SOOTHE LIQ STR/KIWI","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"43900076946"},{"Id":400899,"FormularyType":"OHP","DrugName":"COMPLEAT ORG LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900076951"},{"Id":400900,"FormularyType":"OHP","DrugName":"COMPLEAT ORG LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900077327"},{"Id":400901,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ STND 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900080617"},{"Id":400902,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ STND 1.4","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900080643"},{"Id":400903,"FormularyType":"OHP","DrugName":"COMPLEAT LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900080988"},{"Id":400904,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900081186"},{"Id":400905,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ BLND 1.2","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900082209"},{"Id":400906,"FormularyType":"OHP","DrugName":"BOOST VHC LIQ STRWBRRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900083968"},{"Id":400907,"FormularyType":"OHP","DrugName":"COMPLEAT PED LIQ ORG BLND","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900084642"},{"Id":400908,"FormularyType":"OHP","DrugName":"BOOST LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900085463"},{"Id":400909,"FormularyType":"OHP","DrugName":"BOOST 1.0CAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900088934"},{"Id":400910,"FormularyType":"OHP","DrugName":"BOOST VHC LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900089434"},{"Id":400911,"FormularyType":"OHP","DrugName":"BOOST 1.0CAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900091359"},{"Id":400912,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900093139"},{"Id":400913,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900093239"},{"Id":400914,"FormularyType":"OHP","DrugName":"BOOST PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900093338"},{"Id":400915,"FormularyType":"OHP","DrugName":"BOOST HIGH LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900094139"},{"Id":400916,"FormularyType":"OHP","DrugName":"NOVASOURCE LIQ RENAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"43900094469"},{"Id":400917,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 20MCG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000325","GenericName":"CHOLECALCIFEROL TAB 20 MCG (800 UNIT)","NDC":"43913020390"},{"Id":400918,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"43975027710"},{"Id":400919,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"43975027810"},{"Id":400920,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"43975027910"},{"Id":400921,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"43975028010"},{"Id":400922,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"43975028110"},{"Id":400923,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"43975028210"},{"Id":400924,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"43975030510"},{"Id":400925,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"43975030610"},{"Id":400926,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"43975032203"},{"Id":400927,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"43975032209"},{"Id":400928,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"43975032250"},{"Id":400929,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"43975032303"},{"Id":400930,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"43975032309"},{"Id":400931,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"43975032350"},{"Id":400932,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"43975044410"},{"Id":400933,"FormularyType":"OHP","DrugName":"TEPMETKO TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533773100320","GenericName":"TEPOTINIB HCL TAB 225 MG","NDC":"44087500003"},{"Id":400934,"FormularyType":"OHP","DrugName":"TEPMETKO TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533773100320","GenericName":"TEPOTINIB HCL TAB 225 MG","NDC":"44087500006"},{"Id":400935,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 7%","DosageForm":"NEBU - Nebulization solution","Strength":"7","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002535","GenericName":"SODIUM CHLORIDE SOLN NEBU 7%","NDC":"44229030760"},{"Id":400936,"FormularyType":"OHP","DrugName":"VORTEX MASK MIS PEDS SML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"44229044085"},{"Id":400937,"FormularyType":"OHP","DrugName":"VORTEX MASK MIS PEDS MED","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"44229044086"},{"Id":400938,"FormularyType":"OHP","DrugName":"TODAY SPONGE MIS","DosageForm":"MISC - Miscellaneous","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"SPERMICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55300010006320","GenericName":"NONOXYNOL-9 VAGINAL SPONGE 1000 MG","NDC":"44376010001"},{"Id":400939,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"44523012016"},{"Id":400940,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"44523041001"},{"Id":400941,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"44523041501"},{"Id":400942,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"44523061701"},{"Id":400943,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"44523061703"},{"Id":400944,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"44523061707"},{"Id":400945,"FormularyType":"OHP","DrugName":"UREA CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"44523061803"},{"Id":400946,"FormularyType":"OHP","DrugName":"UREA CRE 39%","DosageForm":"CREA - Cream","Strength":"39","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003724","GenericName":"UREA CREAM 39%","NDC":"44523080108"},{"Id":400947,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302110","GenericName":"AMPICILLIN SODIUM FOR INJ 250 MG","NDC":"44567010010"},{"Id":400948,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"44567010110"},{"Id":400949,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"44567010210"},{"Id":400950,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"44567010310"},{"Id":400951,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"44567010401"},{"Id":400952,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"44567012025"},{"Id":400953,"FormularyType":"OHP","DrugName":"CEFEPIME HCL INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"44567013010"},{"Id":400954,"FormularyType":"OHP","DrugName":"CEFEPIME HCL INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"44567013110"},{"Id":400955,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"44567014501"},{"Id":400956,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"44567014510"},{"Id":400957,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"44567014601"},{"Id":400958,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"44567014610"},{"Id":400959,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"44567015010"},{"Id":400960,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"44567021010"},{"Id":400961,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"44567021110"},{"Id":400962,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"44567021201"},{"Id":400963,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102105","GenericName":"NAFCILLIN SODIUM FOR INJ 1 GM","NDC":"44567022110"},{"Id":400964,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"44567022210"},{"Id":400965,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"44567022301"},{"Id":400966,"FormularyType":"OHP","DrugName":"CEFTAZIDIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002110","GenericName":"CEFTAZIDIME FOR INJ 1 GM","NDC":"44567023525"},{"Id":400967,"FormularyType":"OHP","DrugName":"CEFTAZIDIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002117","GenericName":"CEFTAZIDIME FOR IV SOLN 2 GM","NDC":"44567023610"},{"Id":400968,"FormularyType":"OHP","DrugName":"CEFTAZIDIME INJ 6GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"6","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300080002120","GenericName":"CEFTAZIDIME FOR INJ 6 GM","NDC":"44567023706"},{"Id":400969,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"44567024010"},{"Id":400970,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"44567024110"},{"Id":400971,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"44567024525"},{"Id":400972,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"44567024585"},{"Id":400973,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"44567024625"},{"Id":400974,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"44567024685"},{"Id":400975,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102117","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 10 GM","NDC":"44567024710"},{"Id":400976,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"44567031110"},{"Id":400977,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 20MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"20000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102135","GenericName":"PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","NDC":"44567031201"},{"Id":400978,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"44567040001"},{"Id":400979,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"44567040010"},{"Id":400980,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"44567040101"},{"Id":400981,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"44567040110"},{"Id":400982,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"44567043524"},{"Id":400983,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"44567043624"},{"Id":400984,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"44567043724"},{"Id":400985,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"44567070025"},{"Id":400986,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"44567070125"},{"Id":400987,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"44567070195"},{"Id":400988,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"44567070225"},{"Id":400989,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"44567070295"},{"Id":400990,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102125","GenericName":"CEFTRIAXONE SODIUM FOR INJ 10 GM","NDC":"44567070301"},{"Id":400991,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"44567070501"},{"Id":400992,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"44567070510"},{"Id":400993,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102110","GenericName":"CEFAZOLIN SODIUM FOR INJ 500 MG","NDC":"44567070625"},{"Id":400994,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"44567070725"},{"Id":400995,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"44567070810"},{"Id":400996,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"44567075001"},{"Id":400997,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"44567075024"},{"Id":400998,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"44567080110"},{"Id":400999,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"44567080210"},{"Id":401000,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"44567080310"},{"Id":401001,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"44567080401"},{"Id":401002,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"44567082001"},{"Id":401003,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"44567082010"},{"Id":401004,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102119","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 2 GM","NDC":"44567084001"},{"Id":401005,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102119","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 2 GM","NDC":"44567084025"},{"Id":401006,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"3","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102121","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 3 GM","NDC":"44567084501"},{"Id":401007,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"3","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102121","GenericName":"CEFAZOLIN SODIUM FOR IV SOLN 3 GM","NDC":"44567084525"},{"Id":401008,"FormularyType":"OHP","DrugName":"VIVONEX POW PEDIATRI","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"45291050766"},{"Id":401009,"FormularyType":"OHP","DrugName":"FOTIVDA CAP 0.89MG","DosageForm":"CAPS - Capsule","Strength":"0.89","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533076250120","GenericName":"TIVOZANIB HCL CAP 0.89 MG (BASE EQUIVALENT)","NDC":"45629008901"},{"Id":401010,"FormularyType":"OHP","DrugName":"FOTIVDA CAP 0.89MG","DosageForm":"CAPS - Capsule","Strength":"0.89","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533076250120","GenericName":"TIVOZANIB HCL CAP 0.89 MG (BASE EQUIVALENT)","NDC":"45629008902"},{"Id":401011,"FormularyType":"OHP","DrugName":"FOTIVDA CAP 1.34MG","DosageForm":"CAPS - Capsule","Strength":"1.34","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533076250130","GenericName":"TIVOZANIB HCL CAP 1.34 MG (BASE EQUIVALENT)","NDC":"45629013401"},{"Id":401012,"FormularyType":"OHP","DrugName":"FOTIVDA CAP 1.34MG","DosageForm":"CAPS - Capsule","Strength":"1.34","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533076250130","GenericName":"TIVOZANIB HCL CAP 1.34 MG (BASE EQUIVALENT)","NDC":"45629013402"},{"Id":401013,"FormularyType":"OHP","DrugName":"OMEGA 3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"45737041110"},{"Id":401014,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"45802000402"},{"Id":401015,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"45802000403"},{"Id":401016,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 2.5%","DosageForm":"OINT - Ointment","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004215","GenericName":"HYDROCORTISONE OINT 2.5%","NDC":"45802001402"},{"Id":401017,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 2.5%","DosageForm":"OINT - Ointment","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004215","GenericName":"HYDROCORTISONE OINT 2.5%","NDC":"45802001405"},{"Id":401018,"FormularyType":"OHP","DrugName":"BETAMETH DIP LOT 0.05%","DosageForm":"LOTN - Lotion","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004105","GenericName":"BETAMETHASONE DIPROPIONATE LOTION 0.05%","NDC":"45802002146"},{"Id":401019,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN SOL 2%","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051020002010","GenericName":"ERYTHROMYCIN SOLN 2%","NDC":"45802003846"},{"Id":401020,"FormularyType":"OHP","DrugName":"SELENIUM SUL LOT 2.5%","DosageForm":"LOTN - Lotion","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTISEBORRHEIC PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90300050004120","GenericName":"SELENIUM SULFIDE LOTION 2.5%","NDC":"45802004064"},{"Id":401021,"FormularyType":"OHP","DrugName":"GENTAMICIN OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050104205","GenericName":"GENTAMICIN SULFATE OINT 0.1%","NDC":"45802004611"},{"Id":401022,"FormularyType":"OHP","DrugName":"GENTAMICIN OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050104205","GenericName":"GENTAMICIN SULFATE OINT 0.1%","NDC":"45802004635"},{"Id":401023,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"45802004811"},{"Id":401024,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"45802004835"},{"Id":401025,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.5%","DosageForm":"OINT - Ointment","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104215","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.5%","NDC":"45802004935"},{"Id":401026,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"45802005405"},{"Id":401027,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"45802005435"},{"Id":401028,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.025%","DosageForm":"OINT - Ointment","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104205","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.025%","NDC":"45802005436"},{"Id":401029,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"45802005505"},{"Id":401030,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"45802005535"},{"Id":401031,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"45802005536"},{"Id":401032,"FormularyType":"OHP","DrugName":"GENTAMICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050103705","GenericName":"GENTAMICIN SULFATE CREAM 0.1%","NDC":"45802005611"},{"Id":401033,"FormularyType":"OHP","DrugName":"GENTAMICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100050103705","GenericName":"GENTAMICIN SULFATE CREAM 0.1%","NDC":"45802005635"},{"Id":401034,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"45802005911"},{"Id":401035,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"45802005935"},{"Id":401036,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"45802006001"},{"Id":401037,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"45802006003"},{"Id":401038,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"45802006070"},{"Id":401039,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"45802006305"},{"Id":401040,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"45802006335"},{"Id":401041,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"45802006336"},{"Id":401042,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"45802006405"},{"Id":401043,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"45802006435"},{"Id":401044,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"45802006436"},{"Id":401045,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103720","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.5%","NDC":"45802006535"},{"Id":401046,"FormularyType":"OHP","DrugName":"ALOGLIPTIN TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27550010100310","GenericName":"ALOGLIPTIN BENZOATE TAB 6.25 MG (BASE EQUIV)","NDC":"45802008765"},{"Id":401047,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"45802008801"},{"Id":401048,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"45802008901"},{"Id":401049,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"45802008902"},{"Id":401050,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"45802009735"},{"Id":401051,"FormularyType":"OHP","DrugName":"MESALAMINE ENE 4GM","DosageForm":"ENEM - Enema","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005105","GenericName":"MESALAMINE ENEMA 4 GM","NDC":"45802009828"},{"Id":401052,"FormularyType":"OHP","DrugName":"MESALAMINE ENE 4GM","DosageForm":"ENEM - Enema","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005105","GenericName":"MESALAMINE ENEMA 4 GM","NDC":"45802009851"},{"Id":401053,"FormularyType":"OHP","DrugName":"ALOGLIPTIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27550010100320","GenericName":"ALOGLIPTIN BENZOATE TAB 12.5 MG (BASE EQUIV)","NDC":"45802010365"},{"Id":401054,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"45802010752"},{"Id":401055,"FormularyType":"OHP","DrugName":"TRIAMCINOLON AER 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"45802010901"},{"Id":401056,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"45802011214"},{"Id":401057,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"45802011222"},{"Id":401058,"FormularyType":"OHP","DrugName":"MOMETASONE SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082102010","GenericName":"MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","NDC":"45802011846"},{"Id":401059,"FormularyType":"OHP","DrugName":"MOMETASONE SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082102010","GenericName":"MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","NDC":"45802011859"},{"Id":401060,"FormularyType":"OHP","DrugName":"MOMETASONE OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082104210","GenericName":"MOMETASONE FUROATE OINT 0.1%","NDC":"45802011937"},{"Id":401061,"FormularyType":"OHP","DrugName":"MOMETASONE OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082104210","GenericName":"MOMETASONE FUROATE OINT 0.1%","NDC":"45802011942"},{"Id":401062,"FormularyType":"OHP","DrugName":"CLINDAMYCIN LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104105","GenericName":"CLINDAMYCIN PHOSPHATE LOTION 1%","NDC":"45802012801"},{"Id":401063,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"45802013326"},{"Id":401064,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"45802013811"},{"Id":401065,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"45802013818"},{"Id":401066,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"45802013835"},{"Id":401067,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"45802013970"},{"Id":401068,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"45802014026"},{"Id":401069,"FormularyType":"OHP","DrugName":"CICLOPIROX SOL 8%","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030002020","GenericName":"CICLOPIROX SOLUTION 8%","NDC":"45802014167"},{"Id":401070,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"45802014301"},{"Id":401071,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"45802014303"},{"Id":401072,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"45802014370"},{"Id":401073,"FormularyType":"OHP","DrugName":"ALOGLIPTIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27550010100330","GenericName":"ALOGLIPTIN BENZOATE TAB 25 MG (BASE EQUIV)","NDC":"45802015065"},{"Id":401074,"FormularyType":"OHP","DrugName":"ALOGLIPTIN/ TAB METFORM","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27992502100320","GenericName":"ALOGLIPTIN-METFORMIN HCL TAB 12.5-500 MG","NDC":"45802016972"},{"Id":401075,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"45802020126"},{"Id":401076,"FormularyType":"OHP","DrugName":"NITROGLYCRN SPR 400MCG","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030002060","GenericName":"NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)","NDC":"45802021001"},{"Id":401077,"FormularyType":"OHP","DrugName":"NITROGLYCRN SPR 400MCG","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030002060","GenericName":"NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)","NDC":"45802021002"},{"Id":401078,"FormularyType":"OHP","DrugName":"ALOGLIPTIN/ TAB METFORM","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27992502100330","GenericName":"ALOGLIPTIN-METFORMIN HCL TAB 12.5-1000 MG","NDC":"45802021172"},{"Id":401079,"FormularyType":"OHP","DrugName":"BENZOYL PER GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004010","GenericName":"BENZOYL PEROXIDE GEL 5%","NDC":"45802021601"},{"Id":401080,"FormularyType":"OHP","DrugName":"BENZOYL PER GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004010","GenericName":"BENZOYL PEROXIDE GEL 5%","NDC":"45802021696"},{"Id":401081,"FormularyType":"OHP","DrugName":"FLUTICASONE OIN 0.005%","DosageForm":"OINT - Ointment","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068104210","GenericName":"FLUTICASONE PROPIONATE OINT 0.005%","NDC":"45802022111"},{"Id":401082,"FormularyType":"OHP","DrugName":"FLUTICASONE OIN 0.005%","DosageForm":"OINT - Ointment","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068104210","GenericName":"FLUTICASONE PROPIONATE OINT 0.005%","NDC":"45802022135"},{"Id":401083,"FormularyType":"OHP","DrugName":"FLUTICASONE OIN 0.005%","DosageForm":"OINT - Ointment","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068104210","GenericName":"FLUTICASONE PROPIONATE OINT 0.005%","NDC":"45802022137"},{"Id":401084,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"45802022211"},{"Id":401085,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"45802022235"},{"Id":401086,"FormularyType":"OHP","DrugName":"FLUTICASONE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550068103710","GenericName":"FLUTICASONE PROPIONATE CREAM 0.05%","NDC":"45802022237"},{"Id":401087,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"45802024414"},{"Id":401088,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"45802024494"},{"Id":401089,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"45802024496"},{"Id":401090,"FormularyType":"OHP","DrugName":"MOMETASONE CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082103710","GenericName":"MOMETASONE FUROATE CREAM 0.1%","NDC":"45802025735"},{"Id":401091,"FormularyType":"OHP","DrugName":"MOMETASONE CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082103710","GenericName":"MOMETASONE FUROATE CREAM 0.1%","NDC":"45802025742"},{"Id":401092,"FormularyType":"OHP","DrugName":"ALOG/PIOGLIT TAB 12.5-30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27994002100325","GenericName":"ALOGLIPTIN-PIOGLITAZONE TAB 12.5-30 MG","NDC":"45802026065"},{"Id":401093,"FormularyType":"OHP","DrugName":"PERMETHRIN CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035003720","GenericName":"PERMETHRIN CREAM 5%","NDC":"45802026937"},{"Id":401094,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"45802027603"},{"Id":401095,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"45802028001"},{"Id":401096,"FormularyType":"OHP","DrugName":"BENZOYL PER GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"45802030801"},{"Id":401097,"FormularyType":"OHP","DrugName":"BENZOYL PER GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"45802030896"},{"Id":401098,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"45802034403"},{"Id":401099,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"45802034405"},{"Id":401100,"FormularyType":"OHP","DrugName":"ALOG/PIOGLIT TAB 25-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27994002100340","GenericName":"ALOGLIPTIN-PIOGLITAZONE TAB 25-15 MG","NDC":"45802035165"},{"Id":401101,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"45802036800"},{"Id":401102,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"45802036853"},{"Id":401103,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"45802036862"},{"Id":401104,"FormularyType":"OHP","DrugName":"BETA DIPROP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020053705","GenericName":"BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%","NDC":"45802037632"},{"Id":401105,"FormularyType":"OHP","DrugName":"BETA DIPROP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020053705","GenericName":"BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%","NDC":"45802037635"},{"Id":401106,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"45802039000"},{"Id":401107,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"45802039001"},{"Id":401108,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"45802039002"},{"Id":401109,"FormularyType":"OHP","DrugName":"ALOG/PIOGLIT TAB 25-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27994002100345","GenericName":"ALOGLIPTIN-PIOGLITAZONE TAB 25-30 MG","NDC":"45802040265"},{"Id":401110,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"45802041926"},{"Id":401111,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"45802041954"},{"Id":401112,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"45802043262"},{"Id":401113,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"45802043411"},{"Id":401114,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"45802043803"},{"Id":401115,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"45802043805"},{"Id":401116,"FormularyType":"OHP","DrugName":"KETOCONAZOLE SHA 2%","DosageForm":"SHAM - Shampoo","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004510","GenericName":"KETOCONAZOLE SHAMPOO 2%","NDC":"45802046564"},{"Id":401117,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"45802048678"},{"Id":401118,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"45802049338"},{"Id":401119,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"45802049535"},{"Id":401120,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"45802049537"},{"Id":401121,"FormularyType":"OHP","DrugName":"ALOG/PIOGLIT TAB 25-45MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27994002100350","GenericName":"ALOGLIPTIN-PIOGLITAZONE TAB 25-45 MG","NDC":"45802049965"},{"Id":401122,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"45802050514"},{"Id":401123,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"45802050584"},{"Id":401124,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"45802051377"},{"Id":401125,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"45802052526"},{"Id":401126,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"45802052555"},{"Id":401127,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"45802056201"},{"Id":401128,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"45802056202"},{"Id":401129,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"45802057824"},{"Id":401130,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"45802057884"},{"Id":401131,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 20MG/ACT","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002040","GenericName":"SUMATRIPTAN NASAL SPRAY 20 MG/ACT","NDC":"45802059800"},{"Id":401132,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 20MG/ACT","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002040","GenericName":"SUMATRIPTAN NASAL SPRAY 20 MG/ACT","NDC":"45802059806"},{"Id":401133,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 5MG/ACT","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002010","GenericName":"SUMATRIPTAN NASAL SPRAY 5 MG/ACT","NDC":"45802061900"},{"Id":401134,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 5MG/ACT","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002010","GenericName":"SUMATRIPTAN NASAL SPRAY 5 MG/ACT","NDC":"45802061906"},{"Id":401135,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"45802062626"},{"Id":401136,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"45802065065"},{"Id":401137,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"45802065075"},{"Id":401138,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"45802065078"},{"Id":401139,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"45802065087"},{"Id":401140,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"45802065125"},{"Id":401141,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"45802070000"},{"Id":401142,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"45802070001"},{"Id":401143,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"45802070002"},{"Id":401144,"FormularyType":"OHP","DrugName":"ACETAMIN SUP 650MG","DosageForm":"SUPP - Suppository","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005220","GenericName":"ACETAMINOPHEN SUPPOS 650 MG","NDC":"45802073030"},{"Id":401145,"FormularyType":"OHP","DrugName":"ACETAMIN SUP 650MG","DosageForm":"SUPP - Suppository","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005220","GenericName":"ACETAMINOPHEN SUPPOS 650 MG","NDC":"45802073032"},{"Id":401146,"FormularyType":"OHP","DrugName":"ACETAMIN SUP 650MG","DosageForm":"SUPP - Suppository","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005220","GenericName":"ACETAMINOPHEN SUPPOS 650 MG","NDC":"45802073033"},{"Id":401147,"FormularyType":"OHP","DrugName":"ACETAMIN SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"45802073200"},{"Id":401148,"FormularyType":"OHP","DrugName":"ACETAMIN SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"45802073230"},{"Id":401149,"FormularyType":"OHP","DrugName":"ACETAMIN SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"45802073233"},{"Id":401150,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"45802075401"},{"Id":401151,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 12.5MG","DosageForm":"SUPP - Suppository","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105205","GenericName":"PROMETHAZINE HCL SUPPOS 12.5 MG","NDC":"45802075800"},{"Id":401152,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 12.5MG","DosageForm":"SUPP - Suppository","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105205","GenericName":"PROMETHAZINE HCL SUPPOS 12.5 MG","NDC":"45802075830"},{"Id":401153,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105210","GenericName":"PROMETHAZINE HCL SUPPOS 25 MG","NDC":"45802075900"},{"Id":401154,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105210","GenericName":"PROMETHAZINE HCL SUPPOS 25 MG","NDC":"45802075930"},{"Id":401155,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"45802082725"},{"Id":401156,"FormularyType":"OHP","DrugName":"ADAPAL/BEN P GEL 0.1-2.5%","DosageForm":"GEL - Gel","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90059902034020","GenericName":"ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5%","NDC":"45802084601"},{"Id":401157,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"45802086800"},{"Id":401158,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"45802086801"},{"Id":401159,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"45802086802"},{"Id":401160,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"45802086803"},{"Id":401161,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"45802086866"},{"Id":401162,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"45802087303"},{"Id":401163,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"45802087305"},{"Id":401164,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"45802088014"},{"Id":401165,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"45802088094"},{"Id":401166,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"45802088096"},{"Id":401167,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"45802089726"},{"Id":401168,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"45802089734"},{"Id":401169,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"45802090094"},{"Id":401170,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"45802090096"},{"Id":401171,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"45802091939"},{"Id":401172,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"45802091987"},{"Id":401173,"FormularyType":"OHP","DrugName":"HYDROCORT LOT 2.5%","DosageForm":"LOTN - Lotion","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004120","GenericName":"HYDROCORTISONE LOTION 2.5%","NDC":"45802093716"},{"Id":401174,"FormularyType":"OHP","DrugName":"HYDROCORT LOT 2.5%","DosageForm":"LOTN - Lotion","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004120","GenericName":"HYDROCORTISONE LOTION 2.5%","NDC":"45802093726"},{"Id":401175,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"45802095226"},{"Id":401176,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"45802095243"},{"Id":401177,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"45802095301"},{"Id":401178,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"45802095701"},{"Id":401179,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"45802095702"},{"Id":401180,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"45802097426"},{"Id":401181,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"45861006701"},{"Id":401182,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"45861006901"},{"Id":401183,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"45861007001"},{"Id":401184,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"45861007101"},{"Id":401185,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"45861008305"},{"Id":401186,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"45861008306"},{"Id":401187,"FormularyType":"OHP","DrugName":"DEXTROAMPHET CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020107005","GenericName":"DEXTROAMPHETAMINE SULFATE CAP ER 24HR 5 MG","NDC":"45963030309"},{"Id":401188,"FormularyType":"OHP","DrugName":"DEXTROAMPHET CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020107010","GenericName":"DEXTROAMPHETAMINE SULFATE CAP ER 24HR 10 MG","NDC":"45963030409"},{"Id":401189,"FormularyType":"OHP","DrugName":"DEXTROAMPHET CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020107015","GenericName":"DEXTROAMPHETAMINE SULFATE CAP ER 24HR 15 MG","NDC":"45963030509"},{"Id":401190,"FormularyType":"OHP","DrugName":"ENULOSE SOL 10GM/15","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"45963043864"},{"Id":401191,"FormularyType":"OHP","DrugName":"CONSTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"45963043963"},{"Id":401192,"FormularyType":"OHP","DrugName":"CONSTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"45963043965"},{"Id":401193,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"45963055511"},{"Id":401194,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"45963055611"},{"Id":401195,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"45963055711"},{"Id":401196,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"45963055750"},{"Id":401197,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"45963067611"},{"Id":401198,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"45963067696"},{"Id":401199,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"45963067711"},{"Id":401200,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"45963067796"},{"Id":401201,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"45963067811"},{"Id":401202,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"45963070911"},{"Id":401203,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"45963070996"},{"Id":401204,"FormularyType":"OHP","DrugName":"READY TO USE ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"46036000003"},{"Id":401205,"FormularyType":"OHP","DrugName":"READY TO USE ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"46036000004"},{"Id":401206,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"46036000086"},{"Id":401207,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"46036000089"},{"Id":401208,"FormularyType":"OHP","DrugName":"GOODSENSE OIL MINERAL","DosageForm":"OIL - Oil","Strength":"99.9","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"46036000168"},{"Id":401209,"FormularyType":"OHP","DrugName":"LAXATIVE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"46036000202"},{"Id":401210,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"46036000335"},{"Id":401211,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"46036000355"},{"Id":401212,"FormularyType":"OHP","DrugName":"MENSTRUAL TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"46036000658"},{"Id":401213,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"46036000737"},{"Id":401214,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"46036000826"},{"Id":401215,"FormularyType":"OHP","DrugName":"ANTACID ULTR CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"46036000841"},{"Id":401216,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"46036000843"},{"Id":401217,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"46036000844"},{"Id":401218,"FormularyType":"OHP","DrugName":"ANTACID ULTR CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"46036000845"},{"Id":401219,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"46036000846"},{"Id":401220,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"46036000847"},{"Id":401221,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"46036000848"},{"Id":401222,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"46036000910"},{"Id":401223,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"46036000911"},{"Id":401224,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"46036000916"},{"Id":401225,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"46036000921"},{"Id":401226,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS CHERRY","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"46036000922"},{"Id":401227,"FormularyType":"OHP","DrugName":"GOODSENSE SUS ANTACID","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"46036000924"},{"Id":401228,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"46036000936"},{"Id":401229,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"46036000955"},{"Id":401230,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"46036000957"},{"Id":401231,"FormularyType":"OHP","DrugName":"EYE ITCH REF DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"46036000967"},{"Id":401232,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"46036000971"},{"Id":401233,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"46036000972"},{"Id":401234,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"46036000973"},{"Id":401235,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"46036000974"},{"Id":401236,"FormularyType":"OHP","DrugName":"LAXATIVE PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"46036000975"},{"Id":401237,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"46122000741"},{"Id":401238,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"46122001431"},{"Id":401239,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"46122001433"},{"Id":401240,"FormularyType":"OHP","DrugName":"GNP CLEARLAX PAK 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"46122001452"},{"Id":401241,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"46122001471"},{"Id":401242,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"46122002026"},{"Id":401243,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122004203"},{"Id":401244,"FormularyType":"OHP","DrugName":"GNP ALCOHOL PAD SWABS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"46122004378"},{"Id":401245,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122005603"},{"Id":401246,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"46122007772"},{"Id":401247,"FormularyType":"OHP","DrugName":"GNP CALCIUM TAB CIT +D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"46122008172"},{"Id":401248,"FormularyType":"OHP","DrugName":"GNP CALCIUM TAB CIT +D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"46122008176"},{"Id":401249,"FormularyType":"OHP","DrugName":"GNP IRON TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"46122008365"},{"Id":401250,"FormularyType":"OHP","DrugName":"GNP IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100320","GenericName":"FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE)","NDC":"46122008402"},{"Id":401251,"FormularyType":"OHP","DrugName":"GNP LITTLE CHW ONES","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"46122008972"},{"Id":401252,"FormularyType":"OHP","DrugName":"CHILD CHEW/ CHW EXTRA C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"46122009072"},{"Id":401253,"FormularyType":"OHP","DrugName":"GNP PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"46122009878"},{"Id":401254,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"46122010126"},{"Id":401255,"FormularyType":"OHP","DrugName":"LICE TRTMNT LIQ 1%","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"46122010846"},{"Id":401256,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"46122014762"},{"Id":401257,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"46122015978"},{"Id":401258,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122017420"},{"Id":401259,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122017460"},{"Id":401260,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"46122017608"},{"Id":401261,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122017708"},{"Id":401262,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"46122020326"},{"Id":401263,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122020926"},{"Id":401264,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122021026"},{"Id":401265,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122021126"},{"Id":401266,"FormularyType":"OHP","DrugName":"GNP GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"46122022163"},{"Id":401267,"FormularyType":"OHP","DrugName":"GNP GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"46122022171"},{"Id":401268,"FormularyType":"OHP","DrugName":"GNP GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"46122022263"},{"Id":401269,"FormularyType":"OHP","DrugName":"GNP ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"46122022575"},{"Id":401270,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"46122025460"},{"Id":401271,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122025515"},{"Id":401272,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122025560"},{"Id":401273,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"46122028460"},{"Id":401274,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122028660"},{"Id":401275,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"46122031270"},{"Id":401276,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"46122031278"},{"Id":401277,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122032226"},{"Id":401278,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"46122035274"},{"Id":401279,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"46122035374"},{"Id":401280,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"46122035474"},{"Id":401281,"FormularyType":"OHP","DrugName":"24 HR NASAL SPR ALLERGY","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"46122038576"},{"Id":401282,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"46122039078"},{"Id":401283,"FormularyType":"OHP","DrugName":"GNP MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"46122039516"},{"Id":401284,"FormularyType":"OHP","DrugName":"GNP TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"46122041403"},{"Id":401285,"FormularyType":"OHP","DrugName":"GNP TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"46122041405"},{"Id":401286,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"46122042326"},{"Id":401287,"FormularyType":"OHP","DrugName":"PAIN RELIEF CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"46122042462"},{"Id":401288,"FormularyType":"OHP","DrugName":"GNP ALLERGY CHW 12.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100510","GenericName":"DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG","NDC":"46122042589"},{"Id":401289,"FormularyType":"OHP","DrugName":"GNP DECONGE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"46122042861"},{"Id":401290,"FormularyType":"OHP","DrugName":"GNP DECONGE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"46122042862"},{"Id":401291,"FormularyType":"OHP","DrugName":"GNP LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"46122042963"},{"Id":401292,"FormularyType":"OHP","DrugName":"GNP ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"46122043078"},{"Id":401293,"FormularyType":"OHP","DrugName":"GNP ANTACID SUS REG ST","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"46122043340"},{"Id":401294,"FormularyType":"OHP","DrugName":"GNP ANTACID SUS COOLMINT","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"46122043440"},{"Id":401295,"FormularyType":"OHP","DrugName":"GNP MILK MAG SUS CHERRY","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"46122043540"},{"Id":401296,"FormularyType":"OHP","DrugName":"GNP MILK MAG SUS MINT","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"46122043640"},{"Id":401297,"FormularyType":"OHP","DrugName":"GNP MILK MAG SUS ORIGINAL","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"46122043740"},{"Id":401298,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"46122044062"},{"Id":401299,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"46122044078"},{"Id":401300,"FormularyType":"OHP","DrugName":"GNP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"46122044162"},{"Id":401301,"FormularyType":"OHP","DrugName":"MICONAZORB POW AF 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"46122044427"},{"Id":401302,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"46122044858"},{"Id":401303,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122044958"},{"Id":401304,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"46122046222"},{"Id":401305,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"46122046261"},{"Id":401306,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"46122046265"},{"Id":401307,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"46122046275"},{"Id":401308,"FormularyType":"OHP","DrugName":"GNP GNTL LAX TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"46122052963"},{"Id":401309,"FormularyType":"OHP","DrugName":"GNP GNTL LAX TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"46122052978"},{"Id":401310,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"46122053551"},{"Id":401311,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"46122053653"},{"Id":401312,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"46122053952"},{"Id":401313,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"46122053965"},{"Id":401314,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"46122054890"},{"Id":401315,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"46122056803"},{"Id":401316,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"46122056807"},{"Id":401317,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"46122058055"},{"Id":401318,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"46122058058"},{"Id":401319,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"46122059341"},{"Id":401320,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"46122059360"},{"Id":401321,"FormularyType":"OHP","DrugName":"GNP ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"46122059602"},{"Id":401322,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"46122059848"},{"Id":401323,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"46122059887"},{"Id":401324,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"46122060851"},{"Id":401325,"FormularyType":"OHP","DrugName":"GNP OMEPRAZO TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"46122061604"},{"Id":401326,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"46122061762"},{"Id":401327,"FormularyType":"OHP","DrugName":"GNP ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"46122061862"},{"Id":401328,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"46122062572"},{"Id":401329,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"46122062962"},{"Id":401330,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"46122062971"},{"Id":401331,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"46122062978"},{"Id":401332,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"46122062981"},{"Id":401333,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"46122063071"},{"Id":401334,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"46122063078"},{"Id":401335,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"46122063262"},{"Id":401336,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122064104"},{"Id":401337,"FormularyType":"OHP","DrugName":"GOODSENSE GEL ART PAIN","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"46122064654"},{"Id":401338,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122064803"},{"Id":401339,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122064804"},{"Id":401340,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122064874"},{"Id":401341,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"46122065162"},{"Id":401342,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"46122065178"},{"Id":401343,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"46122066315"},{"Id":401344,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG CHER","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122066515"},{"Id":401345,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG FRT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122066678"},{"Id":401346,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"46122066978"},{"Id":401347,"FormularyType":"OHP","DrugName":"GNP OLOPATAD SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"46122067127"},{"Id":401348,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"46122067264"},{"Id":401349,"FormularyType":"OHP","DrugName":"GNP ZINC OXI OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"46122067646"},{"Id":401350,"FormularyType":"OHP","DrugName":"ALLERGY RLF LIQ 50/20ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"46122068526"},{"Id":401351,"FormularyType":"OHP","DrugName":"GNP HEADACH TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"46122069078"},{"Id":401352,"FormularyType":"OHP","DrugName":"GNP ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"46122069178"},{"Id":401353,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"46122069272"},{"Id":401354,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"46122069278"},{"Id":401355,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"46122069285"},{"Id":401356,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"46122069378"},{"Id":401357,"FormularyType":"OHP","DrugName":"SLEEP-AID MS CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"46122069572"},{"Id":401358,"FormularyType":"OHP","DrugName":"GNP PAIN REL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"46122069662"},{"Id":401359,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"46122069962"},{"Id":401360,"FormularyType":"OHP","DrugName":"GNP SENNA LX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"46122070278"},{"Id":401361,"FormularyType":"OHP","DrugName":"GNP IBUPROFE TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"46122070860"},{"Id":401362,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"46122071560"},{"Id":401363,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122071615"},{"Id":401364,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122071660"},{"Id":401365,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"46122071760"},{"Id":401366,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122071860"},{"Id":401367,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"46122071960"},{"Id":401368,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122072025"},{"Id":401369,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"46122072425"},{"Id":401370,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122072571"},{"Id":401371,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"46122073115"},{"Id":401372,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"46122073208"},{"Id":401373,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"46122073360"},{"Id":401374,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"46122073408"},{"Id":401375,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"46122073565"},{"Id":401376,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"46122073575"},{"Id":401377,"FormularyType":"OHP","DrugName":"GNP ESOMEPRA CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122073603"},{"Id":401378,"FormularyType":"OHP","DrugName":"GNP ESOMEPRA CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122073604"},{"Id":401379,"FormularyType":"OHP","DrugName":"GNP ESOMEPRA CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"46122073674"},{"Id":401380,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"46122073763"},{"Id":401381,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"46122073771"},{"Id":401382,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"46122074038"},{"Id":401383,"FormularyType":"OHP","DrugName":"GNP MAG CITR SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"46122074138"},{"Id":401384,"FormularyType":"OHP","DrugName":"GNP DICLOFEN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"46122075237"},{"Id":401385,"FormularyType":"OHP","DrugName":"GNP DICLOFEN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"46122075252"},{"Id":401386,"FormularyType":"OHP","DrugName":"GNP DICLOFEN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"46122075253"},{"Id":401387,"FormularyType":"OHP","DrugName":"GNP LICE KIL SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"46122075929"},{"Id":401388,"FormularyType":"OHP","DrugName":"GNP SLEEP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"46122076351"},{"Id":401389,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"46122076434"},{"Id":401390,"FormularyType":"OHP","DrugName":"GNP GNTL LAX TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"46122076711"},{"Id":401391,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"46122076836"},{"Id":401392,"FormularyType":"OHP","DrugName":"GNP MOTION CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"46122077451"},{"Id":401393,"FormularyType":"OHP","DrugName":"SLEEP-AID MS CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"46122077564"},{"Id":401394,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"46122077958"},{"Id":401395,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"46122077966"},{"Id":401396,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"46122078734"},{"Id":401397,"FormularyType":"OHP","DrugName":"GNP SLEEP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"46122078815"},{"Id":401398,"FormularyType":"OHP","DrugName":"MICONAZORB POW AF 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"46122078929"},{"Id":401399,"FormularyType":"OHP","DrugName":"GNP ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"46122079166"},{"Id":401400,"FormularyType":"OHP","DrugName":"GNP ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"46122079167"},{"Id":401401,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"46122079329"},{"Id":401402,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"46122080529"},{"Id":401403,"FormularyType":"OHP","DrugName":"GNP NALOXONE SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"46122081271"},{"Id":401404,"FormularyType":"OHP","DrugName":"LUNG PERFM MIS METER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"46241000536"},{"Id":401405,"FormularyType":"OHP","DrugName":"SPS SUS 15GM/60","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001805","GenericName":"SODIUM POLYSTYRENE SULFONATE SUSP 15 GM/60ML","NDC":"46287000601"},{"Id":401406,"FormularyType":"OHP","DrugName":"SPS SUS 30GM/120","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001870","GenericName":"SODIUM POLYSTYRENE SULFONATE RECTAL SUSP 30 GM/120ML","NDC":"46287000604"},{"Id":401407,"FormularyType":"OHP","DrugName":"SPS SUS 15GM/60","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001805","GenericName":"SODIUM POLYSTYRENE SULFONATE SUSP 15 GM/60ML","NDC":"46287000660"},{"Id":401408,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"46287001216"},{"Id":401409,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"46672086046"},{"Id":401410,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"47335000788"},{"Id":401411,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"47335006186"},{"Id":401412,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"47335006286"},{"Id":401413,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"47335006386"},{"Id":401414,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"47335017148"},{"Id":401415,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"47335017149"},{"Id":401416,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"47335017923"},{"Id":401417,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902107210","GenericName":"CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 10-100 MG","NDC":"47335018688"},{"Id":401418,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902107220","GenericName":"CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-100 MG","NDC":"47335018788"},{"Id":401419,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902107230","GenericName":"CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-250 MG","NDC":"47335018888"},{"Id":401420,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"47335022090"},{"Id":401421,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"47335023583"},{"Id":401422,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"47335023596"},{"Id":401423,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"47335023683"},{"Id":401424,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"47335023783"},{"Id":401425,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"47335027641"},{"Id":401426,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"47335027723"},{"Id":401427,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"47335028926"},{"Id":401428,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"47335028927"},{"Id":401429,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"47335029040"},{"Id":401430,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"47335029044"},{"Id":401431,"FormularyType":"OHP","DrugName":"ODOMZO CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21370060200120","GenericName":"SONIDEGIB PHOSPHATE CAP 200 MG (BASE EQUIVALENT)","NDC":"47335030383"},{"Id":401432,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"47335032186"},{"Id":401433,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"47335032213"},{"Id":401434,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"47335032286"},{"Id":401435,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"47335032683"},{"Id":401436,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"47335032688"},{"Id":401437,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"47335037983"},{"Id":401438,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"47335038083"},{"Id":401439,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"47335047281"},{"Id":401440,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"47335047583"},{"Id":401441,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"47335048583"},{"Id":401442,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"47335048588"},{"Id":401443,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 500MG","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"47335053981"},{"Id":401444,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"47335058281"},{"Id":401445,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"47335058381"},{"Id":401446,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"47335058481"},{"Id":401447,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"47335058583"},{"Id":401448,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"47335058683"},{"Id":401449,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"47335058788"},{"Id":401450,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"47335058888"},{"Id":401451,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"47335060083"},{"Id":401452,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"47335061381"},{"Id":401453,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 750MG","DosageForm":"TBCR - Tablet ER","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000460","GenericName":"NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC)","NDC":"47335061481"},{"Id":401454,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"47335063149"},{"Id":401455,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"47335063249"},{"Id":401456,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"47335063349"},{"Id":401457,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"47335066862"},{"Id":401458,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"47335066868"},{"Id":401459,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117030","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","NDC":"47335067013"},{"Id":401460,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117030","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","NDC":"47335067081"},{"Id":401461,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117030","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","NDC":"47335067083"},{"Id":401462,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117040","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","NDC":"47335067113"},{"Id":401463,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117040","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","NDC":"47335067181"},{"Id":401464,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117040","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","NDC":"47335067183"},{"Id":401465,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117050","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","NDC":"47335067213"},{"Id":401466,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117050","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","NDC":"47335067281"},{"Id":401467,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117050","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","NDC":"47335067283"},{"Id":401468,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117060","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","NDC":"47335067313"},{"Id":401469,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117060","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","NDC":"47335067381"},{"Id":401470,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117060","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","NDC":"47335067383"},{"Id":401471,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"47335067513"},{"Id":401472,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"47335067581"},{"Id":401473,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"47335067613"},{"Id":401474,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"47335067681"},{"Id":401475,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"47335067713"},{"Id":401476,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"47335067781"},{"Id":401477,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"47335067813"},{"Id":401478,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"47335067881"},{"Id":401479,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"47335067981"},{"Id":401480,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"47335068688"},{"Id":401481,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"47335068788"},{"Id":401482,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"47335068888"},{"Id":401483,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"47335068988"},{"Id":401484,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"47335069088"},{"Id":401485,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"47335069188"},{"Id":401486,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"47335069288"},{"Id":401487,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"47335069388"},{"Id":401488,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"47335070349"},{"Id":401489,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"47335070352"},{"Id":401490,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"47335070354"},{"Id":401491,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"47335070649"},{"Id":401492,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"47335070652"},{"Id":401493,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"47335070654"},{"Id":401494,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"47335070713"},{"Id":401495,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"47335070786"},{"Id":401496,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"47335071013"},{"Id":401497,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"47335071086"},{"Id":401498,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"47335071113"},{"Id":401499,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"47335071186"},{"Id":401500,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"47335071213"},{"Id":401501,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"47335071286"},{"Id":401502,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"47335072183"},{"Id":401503,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"47335072283"},{"Id":401504,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"47335075649"},{"Id":401505,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"47335075652"},{"Id":401506,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"47335077991"},{"Id":401507,"FormularyType":"OHP","DrugName":"GALANTAMINE CAP 8MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030107020","GenericName":"GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG","NDC":"47335083583"},{"Id":401508,"FormularyType":"OHP","DrugName":"GALANTAMINE CAP 16MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030107030","GenericName":"GALANTAMINE HYDROBROMIDE CAP ER 24HR 16 MG","NDC":"47335083683"},{"Id":401509,"FormularyType":"OHP","DrugName":"GALANTAMINE CAP 24MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"24","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030107040","GenericName":"GALANTAMINE HYDROBROMIDE CAP ER 24HR 24 MG","NDC":"47335083783"},{"Id":401510,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"47335089021"},{"Id":401511,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"47335089072"},{"Id":401512,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"47335089074"},{"Id":401513,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"47335089080"},{"Id":401514,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"47335089121"},{"Id":401515,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"47335089172"},{"Id":401516,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"47335089174"},{"Id":401517,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"47335089180"},{"Id":401518,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"47335089221"},{"Id":401519,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"47335089272"},{"Id":401520,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"47335089274"},{"Id":401521,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"47335089280"},{"Id":401522,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"47335089374"},{"Id":401523,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"47335089380"},{"Id":401524,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"47335089481"},{"Id":401525,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"47335089483"},{"Id":401526,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"47335091886"},{"Id":401527,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"47335092286"},{"Id":401528,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"47335092860"},{"Id":401529,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"47335092867"},{"Id":401530,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"47335092921"},{"Id":401531,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"47335092972"},{"Id":401532,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"47335092974"},{"Id":401533,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"47335092980"},{"Id":401534,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"47335093021"},{"Id":401535,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"47335093072"},{"Id":401536,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"47335093074"},{"Id":401537,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"47335093080"},{"Id":401538,"FormularyType":"OHP","DrugName":"LEUPROLIDE INJ 1MG/0.2","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"47335093640"},{"Id":401539,"FormularyType":"OHP","DrugName":"AZELASTINE DRO 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802006102020","GenericName":"AZELASTINE HCL OPHTH SOLN 0.05%","NDC":"47335093890"},{"Id":401540,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"47335094386"},{"Id":401541,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"47335095618"},{"Id":401542,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"47335095681"},{"Id":401543,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"47335095688"},{"Id":401544,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"47335098086"},{"Id":401545,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"47335099301"},{"Id":401546,"FormularyType":"OHP","DrugName":"MICROCHAMBER MIS","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"47360001722"},{"Id":401547,"FormularyType":"OHP","DrugName":"MICROSPACER MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"47360017201"},{"Id":401548,"FormularyType":"OHP","DrugName":"MICROCHAMBER MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"47360017202"},{"Id":401549,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"47469000511"},{"Id":401550,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"47469000928"},{"Id":401551,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"47469004040"},{"Id":401552,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"47469004409"},{"Id":401553,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG TR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"47469004835"},{"Id":401554,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"47469005105"},{"Id":401555,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"47469005865"},{"Id":401556,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 10000UNT","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"47469006014"},{"Id":401557,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"47469006076"},{"Id":401558,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"47469006211"},{"Id":401559,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"47469006398"},{"Id":401560,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"47469007144"},{"Id":401561,"FormularyType":"OHP","DrugName":"MELATIONIN DRO 5MG/ML","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000960","GenericName":"MELATONIN LIQUID 5 MG/ML","NDC":"47469007149"},{"Id":401562,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"47469007150"},{"Id":401563,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"47469007164"},{"Id":401564,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"47469007166"},{"Id":401565,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"47469007168"},{"Id":401566,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"47469007170"},{"Id":401567,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"47469007281"},{"Id":401568,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"47469007331"},{"Id":401569,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"47469007332"},{"Id":401570,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 1MG/4ML","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000920","GenericName":"MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML)","NDC":"47469007402"},{"Id":401571,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 2.5MG","DosageForm":"LIQD - Liquid","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000920","GenericName":"MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML)","NDC":"47469007405"},{"Id":401572,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"47469007585"},{"Id":401573,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"47469007586"},{"Id":401574,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"47469007668"},{"Id":401575,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"47469007683"},{"Id":401576,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"47469007686"},{"Id":401577,"FormularyType":"OHP","DrugName":"MEDIQUE ASPI TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"47682011613"},{"Id":401578,"FormularyType":"OHP","DrugName":"MEDIQUE ASPI TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"47682011647"},{"Id":401579,"FormularyType":"OHP","DrugName":"MEDIQUE ASPI TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"47682011664"},{"Id":401580,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682014513"},{"Id":401581,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682014536"},{"Id":401582,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682014548"},{"Id":401583,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682014564"},{"Id":401584,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682017513"},{"Id":401585,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682017533"},{"Id":401586,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682017548"},{"Id":401587,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682017564"},{"Id":401588,"FormularyType":"OHP","DrugName":"DIPHEN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"47682018447"},{"Id":401589,"FormularyType":"OHP","DrugName":"DIPHEN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"47682018464"},{"Id":401590,"FormularyType":"OHP","DrugName":"LORADAMED TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"47682020312"},{"Id":401591,"FormularyType":"OHP","DrugName":"LORADAMED TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"47682020350"},{"Id":401592,"FormularyType":"OHP","DrugName":"MEDI-FIRST CRE HYDROCOR","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"47682021135"},{"Id":401593,"FormularyType":"OHP","DrugName":"MEDI-FIRST CRE HYDROCOR","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"47682021173"},{"Id":401594,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"47682022312"},{"Id":401595,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"47682022335"},{"Id":401596,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"47682022373"},{"Id":401597,"FormularyType":"OHP","DrugName":"PAIN-OFF TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"47682022813"},{"Id":401598,"FormularyType":"OHP","DrugName":"PAIN-OFF TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"47682022833"},{"Id":401599,"FormularyType":"OHP","DrugName":"PAIN-OFF TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"47682022847"},{"Id":401600,"FormularyType":"OHP","DrugName":"PAIN-OFF TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"47682022864"},{"Id":401601,"FormularyType":"OHP","DrugName":"CHLORPHEN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"47682024148"},{"Id":401602,"FormularyType":"OHP","DrugName":"CHLORPHEN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"47682024164"},{"Id":401603,"FormularyType":"OHP","DrugName":"AMINOFEN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682025303"},{"Id":401604,"FormularyType":"OHP","DrugName":"ADDAPRIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"47682025314"},{"Id":401605,"FormularyType":"OHP","DrugName":"MEDI-MECLIZI TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"47682047915"},{"Id":401606,"FormularyType":"OHP","DrugName":"MEDI-MECLIZI TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"47682047933"},{"Id":401607,"FormularyType":"OHP","DrugName":"MEDI-FIRST CHW ANT 420","DosageForm":"CHEW - Tablet Chewable","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000505","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 420 MG","NDC":"47682080213"},{"Id":401608,"FormularyType":"OHP","DrugName":"MEDI-FIRST CHW ANT 420","DosageForm":"CHEW - Tablet Chewable","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000505","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 420 MG","NDC":"47682080233"},{"Id":401609,"FormularyType":"OHP","DrugName":"MEDI-FIRST CHW ANT 420","DosageForm":"CHEW - Tablet Chewable","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000505","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 420 MG","NDC":"47682080248"},{"Id":401610,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682080313"},{"Id":401611,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682080333"},{"Id":401612,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"47682080348"},{"Id":401613,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682080413"},{"Id":401614,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682080433"},{"Id":401615,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"47682080448"},{"Id":401616,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB 325 ASP","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"47682080513"},{"Id":401617,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB 325 ASP","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"47682080533"},{"Id":401618,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB 325 ASP","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"47682080548"},{"Id":401619,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB IBU 200","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"47682080813"},{"Id":401620,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB IBU 200","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"47682080830"},{"Id":401621,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB IBU 200","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"47682080833"},{"Id":401622,"FormularyType":"OHP","DrugName":"MEDI-FIRST TAB IBU 200","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"47682080848"},{"Id":401623,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"47781010444"},{"Id":401624,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"47781017401"},{"Id":401625,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"47781017601"},{"Id":401626,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"47781017801"},{"Id":401627,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"47781017901"},{"Id":401628,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"47781018001"},{"Id":401629,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"47781019601"},{"Id":401630,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"47781019605"},{"Id":401631,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"47781022901"},{"Id":401632,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"47781022905"},{"Id":401633,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"47781023001"},{"Id":401634,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"47781023005"},{"Id":401635,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"47781023063"},{"Id":401636,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"47781026301"},{"Id":401637,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"47781026305"},{"Id":401638,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"47781026401"},{"Id":401639,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"47781026405"},{"Id":401640,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"47781026501"},{"Id":401641,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"47781026505"},{"Id":401642,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"47781030701"},{"Id":401643,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"47781030801"},{"Id":401644,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI TAB ER 180MG","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100405","GenericName":"PYRIDOSTIGMINE BROMIDE TAB ER 180 MG","NDC":"47781033530"},{"Id":401645,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"47781035503"},{"Id":401646,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"47781035511"},{"Id":401647,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"47781035603"},{"Id":401648,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"47781035611"},{"Id":401649,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"47781035703"},{"Id":401650,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"47781035711"},{"Id":401651,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"47781035803"},{"Id":401652,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"47781035811"},{"Id":401653,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"47781038426"},{"Id":401654,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"47781040604"},{"Id":401655,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"47781040704"},{"Id":401656,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"47781040804"},{"Id":401657,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"47781041904"},{"Id":401658,"FormularyType":"OHP","DrugName":"FENTANYL DIS 12MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008610","GenericName":"FENTANYL TD PATCH 72HR 12 MCG/HR","NDC":"47781042347"},{"Id":401659,"FormularyType":"OHP","DrugName":"FENTANYL DIS 25MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008620","GenericName":"FENTANYL TD PATCH 72HR 25 MCG/HR","NDC":"47781042447"},{"Id":401660,"FormularyType":"OHP","DrugName":"FENTANYL DIS 50MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008630","GenericName":"FENTANYL TD PATCH 72HR 50 MCG/HR","NDC":"47781042647"},{"Id":401661,"FormularyType":"OHP","DrugName":"FENTANYL DIS 75MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008640","GenericName":"FENTANYL TD PATCH 72HR 75 MCG/HR","NDC":"47781042747"},{"Id":401662,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"47781042811"},{"Id":401663,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"47781042847"},{"Id":401664,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"47781046813"},{"Id":401665,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"47781046913"},{"Id":401666,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"47781047013"},{"Id":401667,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"47781048328"},{"Id":401668,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"47781048401"},{"Id":401669,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"47781048428"},{"Id":401670,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"47781048501"},{"Id":401671,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"47781048528"},{"Id":401672,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"47781048601"},{"Id":401673,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"47781048677"},{"Id":401674,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"47781048777"},{"Id":401675,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"47781048801"},{"Id":401676,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"47781048877"},{"Id":401677,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"47781056201"},{"Id":401678,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"47781056301"},{"Id":401679,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"47781056401"},{"Id":401680,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"47781056501"},{"Id":401681,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"47781056601"},{"Id":401682,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"47781056701"},{"Id":401683,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"47781056801"},{"Id":401684,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000325","GenericName":"DISULFIRAM TAB 250 MG","NDC":"47781060730"},{"Id":401685,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"47781064010"},{"Id":401686,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"47781064090"},{"Id":401687,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"47781064310"},{"Id":401688,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"47781064390"},{"Id":401689,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"47781064610"},{"Id":401690,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"47781064690"},{"Id":401691,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"47781064910"},{"Id":401692,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"47781064990"},{"Id":401693,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"47781065110"},{"Id":401694,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"47781065190"},{"Id":401695,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"47781065410"},{"Id":401696,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"47781065490"},{"Id":401697,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"47781065710"},{"Id":401698,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"47781065790"},{"Id":401699,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"47781065910"},{"Id":401700,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"47781065990"},{"Id":401701,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"47781066210"},{"Id":401702,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"47781066290"},{"Id":401703,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"47781066510"},{"Id":401704,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"47781066590"},{"Id":401705,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"47781066810"},{"Id":401706,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"47781066890"},{"Id":401707,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"47781067110"},{"Id":401708,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"47781067190"},{"Id":401709,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"47781091022"},{"Id":401710,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"47781091091"},{"Id":401711,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"47781091193"},{"Id":401712,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"47781091401"},{"Id":401713,"FormularyType":"OHP","DrugName":"TAKHZYRO INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLASMA KALLIKREIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8584204020E510","GenericName":"LANADELUMAB-FLYO SOLN PREF SYRINGE 150 MG/ML","NDC":"47783064501"},{"Id":401714,"FormularyType":"OHP","DrugName":"TAKHZYRO INJ 300/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLASMA KALLIKREIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8584204020E520","GenericName":"LANADELUMAB-FLYO SOLN PREF SYRINGE 300 MG/2ML (150 MG/ML)","NDC":"47783064601"},{"Id":401715,"FormularyType":"OHP","DrugName":"PHOSPHOLINE SOL 0.125%OP","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86502020102115","GenericName":"ECHOTHIOPHATE IODIDE OPHTH FOR SOLN 0.125%","NDC":"48102005305"},{"Id":401716,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN OIN 5MG/GM","DosageForm":"OINT - Ointment","Strength":"5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101025004210","GenericName":"ERYTHROMYCIN OPHTH OINT 5 MG/GM","NDC":"48102005711"},{"Id":401717,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"48107000057"},{"Id":401718,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000310","GenericName":"NIACINAMIDE TAB 100 MG","NDC":"48107000589"},{"Id":401719,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000340","GenericName":"NIACIN TAB 250 MG","NDC":"48107002489"},{"Id":401720,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"48433010401"},{"Id":401721,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"48433010501"},{"Id":401722,"FormularyType":"OHP","DrugName":"CALC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"48433010601"},{"Id":401723,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"48433010801"},{"Id":401724,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"48433010901"},{"Id":401725,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP OIL 1000","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"48433011001"},{"Id":401726,"FormularyType":"OHP","DrugName":"PRENATAL TAB IRON","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"48433011201"},{"Id":401727,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"48433012901"},{"Id":401728,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"48433020230"},{"Id":401729,"FormularyType":"OHP","DrugName":"ANTACID SUS REG ST","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"48433020430"},{"Id":401730,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"48433021105"},{"Id":401731,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"48433021905"},{"Id":401732,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"48433021940"},{"Id":401733,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 100/10ML","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"48433022010"},{"Id":401734,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 100/10ML","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"48433022040"},{"Id":401735,"FormularyType":"OHP","DrugName":"VCF VAGINAL GEL CONTRACE","DosageForm":"GEL - Gel","Strength":"4","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"SPERMICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55300010004040","GenericName":"NONOXYNOL-9 GEL 4%","NDC":"48723010531"},{"Id":401736,"FormularyType":"OHP","DrugName":"CLINPRO 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"48878312004"},{"Id":401737,"FormularyType":"OHP","DrugName":"CLINPRO 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"48878313004"},{"Id":401738,"FormularyType":"OHP","DrugName":"CLINPRO 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"48878314004"},{"Id":401739,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"48985000150"},{"Id":401740,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"48985000151"},{"Id":401741,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"48985000152"},{"Id":401742,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"48985000154"},{"Id":401743,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"48985000155"},{"Id":401744,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"48985000156"},{"Id":401745,"FormularyType":"OHP","DrugName":"NICOTINE SYS KIT TRANSDER","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005006430","GenericName":"NICOTINE TD PATCH 24 HR KIT 21-14-7 MG/24HR","NDC":"48985000157"},{"Id":401746,"FormularyType":"OHP","DrugName":"TABLET CUTTR MIS /CRUSHER","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97700000000000","GenericName":"*MISC. DEVICES**","NDC":"49022007425"},{"Id":401747,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1% VAG","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003705","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 1%","NDC":"49022008436"},{"Id":401748,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 SUP 100MG","DosageForm":"SUPP - Suppository","Strength":"100","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050105205","GenericName":"MICONAZOLE NITRATE VAGINAL SUPPOS 100 MG","NDC":"49022008437"},{"Id":401749,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"49022008441"},{"Id":401750,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"49022008444"},{"Id":401751,"FormularyType":"OHP","DrugName":"STOP LICE LIQ MAX ST","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902100940","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%","NDC":"49022012231"},{"Id":401752,"FormularyType":"OHP","DrugName":"LICE TREATMT LIQ 1%","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"49022014067"},{"Id":401753,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA T+PLUS","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"49022017222"},{"Id":401754,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA T+PLUS","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"49022022411"},{"Id":401755,"FormularyType":"OHP","DrugName":"SCALP RELIEF SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075002005","GenericName":"HYDROCORTISONE SOLN 1%","NDC":"49022031003"},{"Id":401756,"FormularyType":"OHP","DrugName":"BENZOYL PER GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"49022045382"},{"Id":401757,"FormularyType":"OHP","DrugName":"ACNE TREATMN GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"49022059840"},{"Id":401758,"FormularyType":"OHP","DrugName":"ACNE FOAMING LIQ WASH 10%","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"49022067498"},{"Id":401759,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1% TRT","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"49022072697"},{"Id":401760,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1% TRT","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"49022072929"},{"Id":401761,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"49035000206"},{"Id":401762,"FormularyType":"OHP","DrugName":"EQ ENEMA ENE DOUBLE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"49035000236"},{"Id":401763,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"49035002272"},{"Id":401764,"FormularyType":"OHP","DrugName":"ALLERGY REL SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"49035002419"},{"Id":401765,"FormularyType":"OHP","DrugName":"MINERAL OIL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"49035003516"},{"Id":401766,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"49035004226"},{"Id":401767,"FormularyType":"OHP","DrugName":"EQ SLEEP-AID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"49035006024"},{"Id":401768,"FormularyType":"OHP","DrugName":"EQ ALLERGY SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"49035006108"},{"Id":401769,"FormularyType":"OHP","DrugName":"EQ TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"49035006716"},{"Id":401770,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"49035008003"},{"Id":401771,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"49035010104"},{"Id":401772,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"49035010608"},{"Id":401773,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"49035011006"},{"Id":401774,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"49035011014"},{"Id":401775,"FormularyType":"OHP","DrugName":"EQ TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"49035012002"},{"Id":401776,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"49035012280"},{"Id":401777,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"49035012307"},{"Id":401778,"FormularyType":"OHP","DrugName":"FIBER THERAP TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"49035014794"},{"Id":401779,"FormularyType":"OHP","DrugName":"EQ ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"49035015712"},{"Id":401780,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"49035016412"},{"Id":401781,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"49035016626"},{"Id":401782,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"49035016634"},{"Id":401783,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035017029"},{"Id":401784,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"49035018121"},{"Id":401785,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"49035018380"},{"Id":401786,"FormularyType":"OHP","DrugName":"EQ ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"49035019008"},{"Id":401787,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"49035019401"},{"Id":401788,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"49035019402"},{"Id":401789,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"49035019502"},{"Id":401790,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"49035019602"},{"Id":401791,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"49035020110"},{"Id":401792,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035020696"},{"Id":401793,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"49035021024"},{"Id":401794,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"49035021737"},{"Id":401795,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"49035023110"},{"Id":401796,"FormularyType":"OHP","DrugName":"EQ ARTHRITIS GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"49035026201"},{"Id":401797,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"49035026917"},{"Id":401798,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"49035026935"},{"Id":401799,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"49035026953"},{"Id":401800,"FormularyType":"OHP","DrugName":"EQ ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"49035027408"},{"Id":401801,"FormularyType":"OHP","DrugName":"EQ CETIRIZIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"49035027601"},{"Id":401802,"FormularyType":"OHP","DrugName":"EQ CETIRIZIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"49035027608"},{"Id":401803,"FormularyType":"OHP","DrugName":"EQ CETIRIZIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"49035027609"},{"Id":401804,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035029108"},{"Id":401805,"FormularyType":"OHP","DrugName":"NAT VEG LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"49035029812"},{"Id":401806,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"49035030601"},{"Id":401807,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"49035030602"},{"Id":401808,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"49035030603"},{"Id":401809,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"49035030609"},{"Id":401810,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49035030882"},{"Id":401811,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035030978"},{"Id":401812,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"49035031207"},{"Id":401813,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"49035031326"},{"Id":401814,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"49035032712"},{"Id":401815,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"49035034403"},{"Id":401816,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"49035034503"},{"Id":401817,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"49035034610"},{"Id":401818,"FormularyType":"OHP","DrugName":"EQ MICONAZ 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"49035034707"},{"Id":401819,"FormularyType":"OHP","DrugName":"EQ LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"49035034924"},{"Id":401820,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035035206"},{"Id":401821,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035035278"},{"Id":401822,"FormularyType":"OHP","DrugName":"EQ ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"49035035590"},{"Id":401823,"FormularyType":"OHP","DrugName":"EQ SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"49035036030"},{"Id":401824,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG CINN","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035036578"},{"Id":401825,"FormularyType":"OHP","DrugName":"EQ ALRGY REL TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"49035036602"},{"Id":401826,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"49035036654"},{"Id":401827,"FormularyType":"OHP","DrugName":"EQ ALRGY REL TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"49035036659"},{"Id":401828,"FormularyType":"OHP","DrugName":"EQ SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"49035037730"},{"Id":401829,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"49035037814"},{"Id":401830,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"49035037926"},{"Id":401831,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"49035038115"},{"Id":401832,"FormularyType":"OHP","DrugName":"EQ STOOL SOF CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"49035038550"},{"Id":401833,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49035041412"},{"Id":401834,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035041578"},{"Id":401835,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035042296"},{"Id":401836,"FormularyType":"OHP","DrugName":"EQ HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"49035043306"},{"Id":401837,"FormularyType":"OHP","DrugName":"EQ HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"49035043308"},{"Id":401838,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035043890"},{"Id":401839,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035044206"},{"Id":401840,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035044260"},{"Id":401841,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035044278"},{"Id":401842,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"49035044301"},{"Id":401843,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"49035044302"},{"Id":401844,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"49035045508"},{"Id":401845,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035045606"},{"Id":401846,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035045660"},{"Id":401847,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"49035045678"},{"Id":401848,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"49035045875"},{"Id":401849,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"49035045887"},{"Id":401850,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"49035045895"},{"Id":401851,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"49035046708"},{"Id":401852,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"49035050534"},{"Id":401853,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"49035050775"},{"Id":401854,"FormularyType":"OHP","DrugName":"SINUS 12-HR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"49035050860"},{"Id":401855,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"49035051026"},{"Id":401856,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035051778"},{"Id":401857,"FormularyType":"OHP","DrugName":"IBUPROFEN JR CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"49035052162"},{"Id":401858,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"49035052614"},{"Id":401859,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"49035052640"},{"Id":401860,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"49035052660"},{"Id":401861,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49035053112"},{"Id":401862,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035053206"},{"Id":401863,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035053260"},{"Id":401864,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035053278"},{"Id":401865,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035055390"},{"Id":401866,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49035056311"},{"Id":401867,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49035056314"},{"Id":401868,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49035056317"},{"Id":401869,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49035056332"},{"Id":401870,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"49035057175"},{"Id":401871,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"49035057195"},{"Id":401872,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"49035058977"},{"Id":401873,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"49035059026"},{"Id":401874,"FormularyType":"OHP","DrugName":"EQ ALLERGY CHW 12.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100510","GenericName":"DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG","NDC":"49035059909"},{"Id":401875,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"49035060004"},{"Id":401876,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035060458"},{"Id":401877,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035060482"},{"Id":401878,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035060490"},{"Id":401879,"FormularyType":"OHP","DrugName":"EQ ALLERGY SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"49035061134"},{"Id":401880,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"49035061246"},{"Id":401881,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"49035061247"},{"Id":401882,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"49035061272"},{"Id":401883,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"49035061287"},{"Id":401884,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035064782"},{"Id":401885,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"49035065071"},{"Id":401886,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"49035065078"},{"Id":401887,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"49035066026"},{"Id":401888,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"49035069309"},{"Id":401889,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"49035069927"},{"Id":401890,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"49035070210"},{"Id":401891,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"49035070301"},{"Id":401892,"FormularyType":"OHP","DrugName":"EQ 1% HYDROC CRE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"49035070726"},{"Id":401893,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"49035073401"},{"Id":401894,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"49035074162"},{"Id":401895,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"49035074178"},{"Id":401896,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"49035077708"},{"Id":401897,"FormularyType":"OHP","DrugName":"SINUS & CONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"49035078008"},{"Id":401898,"FormularyType":"OHP","DrugName":"SINUS & CONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"49035078022"},{"Id":401899,"FormularyType":"OHP","DrugName":"EQ LORATADIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"49035080603"},{"Id":401900,"FormularyType":"OHP","DrugName":"EQ LORATADIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"49035080609"},{"Id":401901,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"49035081227"},{"Id":401902,"FormularyType":"OHP","DrugName":"EQ CIMETIDIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"49035082072"},{"Id":401903,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"49035085478"},{"Id":401904,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49035086950"},{"Id":401905,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"49035087303"},{"Id":401906,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"49035087309"},{"Id":401907,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"49035087310"},{"Id":401908,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"49035089726"},{"Id":401909,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"49035089734"},{"Id":401910,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"49035090112"},{"Id":401911,"FormularyType":"OHP","DrugName":"EQ LAXATIVE POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"49035090603"},{"Id":401912,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49035091212"},{"Id":401913,"FormularyType":"OHP","DrugName":"EQ PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49035091912"},{"Id":401914,"FormularyType":"OHP","DrugName":"EQ PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49035091920"},{"Id":401915,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"49035092998"},{"Id":401916,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"49035094616"},{"Id":401917,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"49035096678"},{"Id":401918,"FormularyType":"OHP","DrugName":"EQ SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"49035096827"},{"Id":401919,"FormularyType":"OHP","DrugName":"EQ ESOME MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"49035098005"},{"Id":401920,"FormularyType":"OHP","DrugName":"EQ ESOME MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"49035098008"},{"Id":401921,"FormularyType":"OHP","DrugName":"EQ ESOME MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"49035098010"},{"Id":401922,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"49035098112"},{"Id":401923,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"49035099562"},{"Id":401924,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"49035099803"},{"Id":401925,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"49035099810"},{"Id":401926,"FormularyType":"OHP","DrugName":"CULTURELLE CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"49100040070"},{"Id":401927,"FormularyType":"OHP","DrugName":"KIDS PROBIOT CHW MULTIVIT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"49100040076"},{"Id":401928,"FormularyType":"OHP","DrugName":"CULTURELLE CHW KIDS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"49100040148"},{"Id":401929,"FormularyType":"OHP","DrugName":"FLUZONE HD INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"65","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002023E620","GenericName":"INFLUENZA VIRUS VAC SPLIT HIGH-DOSE PF SUSP PREF SYR 0.5ML","NDC":"49281012565"},{"Id":401930,"FormularyType":"OHP","DrugName":"FLUZONE HD INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"65","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002023E620","GenericName":"INFLUENZA VIRUS VAC SPLIT HIGH-DOSE PF SUSP PREF SYR 0.5ML","NDC":"49281012588"},{"Id":401931,"FormularyType":"OHP","DrugName":"TENIVAC INJ 5-2LF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990002201808","GenericName":"TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 5-2 LF/0.5ML","NDC":"49281021510"},{"Id":401932,"FormularyType":"OHP","DrugName":"TENIVAC INJ 5-2LF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990002201808","GenericName":"TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 5-2 LF/0.5ML","NDC":"49281021515"},{"Id":401933,"FormularyType":"OHP","DrugName":"TENIVAC INJ 5-2LF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990002201808","GenericName":"TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 5-2 LF/0.5ML","NDC":"49281021558"},{"Id":401934,"FormularyType":"OHP","DrugName":"TENIVAC INJ 5-2LF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990002201808","GenericName":"TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 5-2 LF/0.5ML","NDC":"49281021588"},{"Id":401935,"FormularyType":"OHP","DrugName":"IMOVAX RABIE INJ 2.5/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100070001900","GenericName":"RABIES VIRUS VACCINE, HDC FOR INJ SUSP","NDC":"49281024658"},{"Id":401936,"FormularyType":"OHP","DrugName":"IMOVAX RABIE INJ 2.5/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100070001900","GenericName":"RABIES VIRUS VACCINE, HDC FOR INJ SUSP","NDC":"49281025251"},{"Id":401937,"FormularyType":"OHP","DrugName":"DAPTACEL INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990003201830","GenericName":"DIPH, ACELLULAR PERT & TET TOX INJ 15 LF-23 MCG-5 LF/0.5ML","NDC":"49281028610"},{"Id":401938,"FormularyType":"OHP","DrugName":"DAPTACEL INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990003201830","GenericName":"DIPH, ACELLULAR PERT & TET TOX INJ 15 LF-23 MCG-5 LF/0.5ML","NDC":"49281028658"},{"Id":401939,"FormularyType":"OHP","DrugName":"ADACEL INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990003221815","GenericName":"TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2-15.5 LF-LF-MCG/0.5ML","NDC":"49281040010"},{"Id":401940,"FormularyType":"OHP","DrugName":"ADACEL INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1899000322E615","GenericName":"TET-DIPH-ACELL PERTUSS AD PREF SYR 5-2-15.5 LF-MCG/0.5ML","NDC":"49281040020"},{"Id":401941,"FormularyType":"OHP","DrugName":"ADACEL INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990003221815","GenericName":"TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2-15.5 LF-LF-MCG/0.5ML","NDC":"49281040058"},{"Id":401942,"FormularyType":"OHP","DrugName":"ADACEL INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1899000322E615","GenericName":"TET-DIPH-ACELL PERTUSS AD PREF SYR 5-2-15.5 LF-MCG/0.5ML","NDC":"49281040089"},{"Id":401943,"FormularyType":"OHP","DrugName":"FLUZONE INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"49281042550"},{"Id":401944,"FormularyType":"OHP","DrugName":"FLUZONE INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"49281042588"},{"Id":401945,"FormularyType":"OHP","DrugName":"MENQUADFI INJ","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200040462000","GenericName":"MENINGOCOCCAL (A, C, Y, AND W-135) TETANUS CONJUGATE VACCINE","NDC":"49281059005"},{"Id":401946,"FormularyType":"OHP","DrugName":"MENQUADFI INJ","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200040462000","GenericName":"MENINGOCOCCAL (A, C, Y, AND W-135) TETANUS CONJUGATE VACCINE","NDC":"49281059010"},{"Id":401947,"FormularyType":"OHP","DrugName":"MENQUADFI INJ","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200040462000","GenericName":"MENINGOCOCCAL (A, C, Y, AND W-135) TETANUS CONJUGATE VACCINE","NDC":"49281059058"},{"Id":401948,"FormularyType":"OHP","DrugName":"DENGVAXIA SUS","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100003101920","GenericName":"DENGUE VIRUS VACCINE LIVE TETRAVALENT FOR SUBCUTANEOUS SUSP","NDC":"49281060501"},{"Id":401949,"FormularyType":"OHP","DrugName":"DENGVAXIA SUS","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100003101920","GenericName":"DENGUE VIRUS VACCINE LIVE TETRAVALENT FOR SUBCUTANEOUS SUSP","NDC":"49281060658"},{"Id":401950,"FormularyType":"OHP","DrugName":"FLUZONE INJ 2025-26","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020201800","GenericName":"INFLUENZA VIRUS VACCINE SPLIT IM SUSP","NDC":"49281064315"},{"Id":401951,"FormularyType":"OHP","DrugName":"FLUZONE INJ 2025-26","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020201800","GenericName":"INFLUENZA VIRUS VACCINE SPLIT IM SUSP","NDC":"49281064378"},{"Id":401952,"FormularyType":"OHP","DrugName":"FLUBLOK INJ 2025-26","DosageForm":"SOSY - Soln Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002085E520","GenericName":"INFLUENZA VIRUS VACC RECOMBINANT HA PF SOLN PREF SYR 0.5 ML","NDC":"49281072510"},{"Id":401953,"FormularyType":"OHP","DrugName":"FLUBLOK INJ 2025-26","DosageForm":"SOSY - Soln Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002085E520","GenericName":"INFLUENZA VIRUS VACC RECOMBINANT HA PF SOLN PREF SYR 0.5 ML","NDC":"49281072588"},{"Id":401954,"FormularyType":"OHP","DrugName":"TYPHIM VI INJ","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720008010E512","GenericName":"TYPHOID VI POLYSACCHARIDE VACC IM SOLN PREF SYR 25 MCG/0.5ML","NDC":"49281079051"},{"Id":401955,"FormularyType":"OHP","DrugName":"TYPHIM VI INJ","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1720008010E512","GenericName":"TYPHOID VI POLYSACCHARIDE VACC IM SOLN PREF SYR 25 MCG/0.5ML","NDC":"49281079088"},{"Id":401956,"FormularyType":"OHP","DrugName":"IPOL INJ INACTIVE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100050001800","GenericName":"POLIOVIRUS VACCINE, IPV INJ SUSP","NDC":"49281086010"},{"Id":401957,"FormularyType":"OHP","DrugName":"IPOL INJ INACTIVE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100050001800","GenericName":"POLIOVIRUS VACCINE, IPV INJ SUSP","NDC":"49281086078"},{"Id":401958,"FormularyType":"OHP","DrugName":"YF-VAX INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100090001910","GenericName":"YELLOW FEVER VACCINE FOR SUBCUTANEOUS SUSPENSION","NDC":"49281091501"},{"Id":401959,"FormularyType":"OHP","DrugName":"YF-VAX INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100090001910","GenericName":"YELLOW FEVER VACCINE FOR SUBCUTANEOUS SUSPENSION","NDC":"49281091558"},{"Id":401960,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"49348016162"},{"Id":401961,"FormularyType":"OHP","DrugName":"SM ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"49348028314"},{"Id":401962,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"49348054237"},{"Id":401963,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"49348063804"},{"Id":401964,"FormularyType":"OHP","DrugName":"SM IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49348082909"},{"Id":401965,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"49348087410"},{"Id":401966,"FormularyType":"OHP","DrugName":"BENLYSTA INJ 200MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9942201500D520","GenericName":"BELIMUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML","NDC":"49401008801"},{"Id":401967,"FormularyType":"OHP","DrugName":"BENLYSTA INJ 200MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9942201500D520","GenericName":"BELIMUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML","NDC":"49401008802"},{"Id":401968,"FormularyType":"OHP","DrugName":"BENLYSTA INJ 200MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9942201500D520","GenericName":"BELIMUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML","NDC":"49401008835"},{"Id":401969,"FormularyType":"OHP","DrugName":"BENLYSTA INJ 200MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9942201500E520","GenericName":"BELIMUMAB SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML","NDC":"49401008842"},{"Id":401970,"FormularyType":"OHP","DrugName":"BENLYSTA INJ 200MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9942201500E520","GenericName":"BELIMUMAB SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML","NDC":"49401008847"},{"Id":401971,"FormularyType":"OHP","DrugName":"BENLYSTA INJ 200MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9942201500D520","GenericName":"BELIMUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML","NDC":"49401008861"},{"Id":401972,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"49452190902"},{"Id":401973,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"49452191001"},{"Id":401974,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"49452233001"},{"Id":401975,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"49452233002"},{"Id":401976,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"49452233003"},{"Id":401977,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"49452363901"},{"Id":401978,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"49452363902"},{"Id":401979,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"49452363903"},{"Id":401980,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"49452363904"},{"Id":401981,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"49452363906"},{"Id":401982,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"49452472001"},{"Id":401983,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"49452472002"},{"Id":401984,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"49452472003"},{"Id":401985,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"49452472004"},{"Id":401986,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"49452472005"},{"Id":401987,"FormularyType":"OHP","DrugName":"MINERAL OIL MED VISC","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452473001"},{"Id":401988,"FormularyType":"OHP","DrugName":"MINERAL OIL MED VISC","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452473002"},{"Id":401989,"FormularyType":"OHP","DrugName":"MINERAL OIL MED VISC","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452473003"},{"Id":401990,"FormularyType":"OHP","DrugName":"MINERAL OIL MED VISC","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452473004"},{"Id":401991,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452474001"},{"Id":401992,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452474002"},{"Id":401993,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452474003"},{"Id":401994,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"49452474005"},{"Id":401995,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"49452557001"},{"Id":401996,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"49452557002"},{"Id":401997,"FormularyType":"OHP","DrugName":"SYRUP SYP NF","DosageForm":"SYRP - Syrup","Strength":"85","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"49452759001"},{"Id":401998,"FormularyType":"OHP","DrugName":"SYRUP SYP NF","DosageForm":"SYRP - Syrup","Strength":"85","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"49452759002"},{"Id":401999,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"49483000301"},{"Id":402000,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"49483000310"},{"Id":402001,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"49483000355"},{"Id":402002,"FormularyType":"OHP","DrugName":"NIACIN CAP 250MG SR","DosageForm":"CPCR - Capsule ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000210","GenericName":"NIACIN CAP ER 250 MG","NDC":"49483001401"},{"Id":402003,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"49483006101"},{"Id":402004,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"49483006301"},{"Id":402005,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"49483006310"},{"Id":402006,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49483007010"},{"Id":402007,"FormularyType":"OHP","DrugName":"SENNA-TIME TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"49483008001"},{"Id":402008,"FormularyType":"OHP","DrugName":"SENNA-TIME TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"49483008010"},{"Id":402009,"FormularyType":"OHP","DrugName":"SENNA-TIME S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"49483008101"},{"Id":402010,"FormularyType":"OHP","DrugName":"SENNA-TIME S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"49483008110"},{"Id":402011,"FormularyType":"OHP","DrugName":"MOTION-TIME CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"49483033301"},{"Id":402012,"FormularyType":"OHP","DrugName":"MOTION-TIME CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"49483033310"},{"Id":402013,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"49483033463"},{"Id":402014,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"49483034001"},{"Id":402015,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"49483034010"},{"Id":402016,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49483034101"},{"Id":402017,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49483034105"},{"Id":402018,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49483034110"},{"Id":402019,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49483034142"},{"Id":402020,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"49483034150"},{"Id":402021,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49483048110"},{"Id":402022,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"49483048112"},{"Id":402023,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"49483060101"},{"Id":402024,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"49483060201"},{"Id":402025,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"49483060250"},{"Id":402026,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"49483060301"},{"Id":402027,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"49483060350"},{"Id":402028,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"49483060401"},{"Id":402029,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"49483060450"},{"Id":402030,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"49483060501"},{"Id":402031,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"49483060509"},{"Id":402032,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"49483060510"},{"Id":402033,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"49483060527"},{"Id":402034,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"49483060550"},{"Id":402035,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"49483060581"},{"Id":402036,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060601"},{"Id":402037,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060603"},{"Id":402038,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060606"},{"Id":402039,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060609"},{"Id":402040,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060610"},{"Id":402041,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060627"},{"Id":402042,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060650"},{"Id":402043,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"49483060681"},{"Id":402044,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"49483060701"},{"Id":402045,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"49483060710"},{"Id":402046,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"49483060727"},{"Id":402047,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"49483060750"},{"Id":402048,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"49483061701"},{"Id":402049,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"49483061750"},{"Id":402050,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"49483061801"},{"Id":402051,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"49483061850"},{"Id":402052,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"49483061901"},{"Id":402053,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"49483061950"},{"Id":402054,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"49483062001"},{"Id":402055,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"49483062010"},{"Id":402056,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"49483062050"},{"Id":402057,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"49483062081"},{"Id":402058,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"49483062101"},{"Id":402059,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"49483062110"},{"Id":402060,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"49483062150"},{"Id":402061,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"49483062181"},{"Id":402062,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"49483062201"},{"Id":402063,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"49483062210"},{"Id":402064,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"49483062250"},{"Id":402065,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"49483062281"},{"Id":402066,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"49483062301"},{"Id":402067,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"49483062309"},{"Id":402068,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"49483062310"},{"Id":402069,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"49483062350"},{"Id":402070,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"49483062401"},{"Id":402071,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"49483062450"},{"Id":402072,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100310","GenericName":"CETIRIZINE HCL TAB 5 MG","NDC":"49483068201"},{"Id":402073,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 1 MCG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000110","GenericName":"PARICALCITOL CAP 1 MCG","NDC":"49483068703"},{"Id":402074,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 2 MCG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000120","GenericName":"PARICALCITOL CAP 2 MCG","NDC":"49483068803"},{"Id":402075,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"49483069250"},{"Id":402076,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"49483069901"},{"Id":402077,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"49483069905"},{"Id":402078,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"49483072001"},{"Id":402079,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.15MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.15","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D520","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000)","NDC":"49502010101"},{"Id":402080,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.15MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.15","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D520","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000)","NDC":"49502010102"},{"Id":402081,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.3MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D540","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","NDC":"49502010201"},{"Id":402082,"FormularyType":"OHP","DrugName":"EPINEPHRINE INJ 0.3MG","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"ANAPHYLAXIS THERAPY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3890004000D540","GenericName":"EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","NDC":"49502010202"},{"Id":402083,"FormularyType":"OHP","DrugName":"EASIVENT MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"49502020701"},{"Id":402084,"FormularyType":"OHP","DrugName":"EASIVENT MIS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"49502020725"},{"Id":402085,"FormularyType":"OHP","DrugName":"EASIVENT MIS MASK SM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"49502020801"},{"Id":402086,"FormularyType":"OHP","DrugName":"EASIVENT MIS MASK MED","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"49502020802"},{"Id":402087,"FormularyType":"OHP","DrugName":"EASIVENT MIS MASK LG","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"49502020803"},{"Id":402088,"FormularyType":"OHP","DrugName":"CIMDUO TAB 300-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902470330","GenericName":"LAMIVUDINE-TENOFOVIR DISOPROXIL FUMARATE TAB 300-300 MG","NDC":"49502045093"},{"Id":402089,"FormularyType":"OHP","DrugName":"PRETOMANID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000063000320","GenericName":"PRETOMANID TAB 200 MG","NDC":"49502047626"},{"Id":402090,"FormularyType":"OHP","DrugName":"RETROVIR INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108085002020","GenericName":"ZIDOVUDINE IV SOLN 10 MG/ML","NDC":"49702021301"},{"Id":402091,"FormularyType":"OHP","DrugName":"RETROVIR INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108085002020","GenericName":"ZIDOVUDINE IV SOLN 10 MG/ML","NDC":"49702021326"},{"Id":402092,"FormularyType":"OHP","DrugName":"TIVICAY TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103015100320","GenericName":"DOLUTEGRAVIR SODIUM TAB 50 MG (BASE EQUIV)","NDC":"49702022813"},{"Id":402093,"FormularyType":"OHP","DrugName":"TRIUMEQ TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903150320","GenericName":"ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB 600-50-300 MG","NDC":"49702023113"},{"Id":402094,"FormularyType":"OHP","DrugName":"JULUCA TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902280320","GenericName":"DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL TAB 50-25 MG (BASE EQ)","NDC":"49702024213"},{"Id":402095,"FormularyType":"OHP","DrugName":"DOVATO TAB 50-300MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902260320","GenericName":"DOLUTEGRAVIR SODIUM-LAMIVUDINE TAB 50-300 MG (BASE EQ)","NDC":"49702024613"},{"Id":402096,"FormularyType":"OHP","DrugName":"DOVATO TAB 50-300MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902260320","GenericName":"DOLUTEGRAVIR SODIUM-LAMIVUDINE TAB 50-300 MG (BASE EQ)","NDC":"49702024633"},{"Id":402097,"FormularyType":"OHP","DrugName":"VOCABRIA TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103010200320","GenericName":"CABOTEGRAVIR SODIUM TAB 30 MG","NDC":"49702024813"},{"Id":402098,"FormularyType":"OHP","DrugName":"RUKOBIA TAB 600MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"600","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102330407420","GenericName":"FOSTEMSAVIR TROMETHAMINE TAB ER 12HR 600 MG","NDC":"49702025018"},{"Id":402099,"FormularyType":"OHP","DrugName":"TIVICAY PD TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12103015107320","GenericName":"DOLUTEGRAVIR SODIUM TAB FOR ORAL SUSP 5 MG (BASE EQUIV)","NDC":"49702025537"},{"Id":402100,"FormularyType":"OHP","DrugName":"TRIUMEQ PD TAB","DosageForm":"TBSO - Tablet Soluble","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903157320","GenericName":"ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB FOR ORAL SUS 60-5-30 MG","NDC":"49702025837"},{"Id":402101,"FormularyType":"OHP","DrugName":"SELZENTRY SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12102060002020","GenericName":"MARAVIROC ORAL SOLN 20 MG/ML","NDC":"49702026055"},{"Id":402102,"FormularyType":"OHP","DrugName":"TRIUMEQ PD TAB","DosageForm":"TBSO - Tablet Soluble","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903157320","GenericName":"ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB FOR ORAL SUS 60-5-30 MG","NDC":"49702027259"},{"Id":402103,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735000180"},{"Id":402104,"FormularyType":"OHP","DrugName":"XMET XCYS POW MAXAMAID","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001457"},{"Id":402105,"FormularyType":"OHP","DrugName":"PKU PERIFLEX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001618"},{"Id":402106,"FormularyType":"OHP","DrugName":"TYR ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001619"},{"Id":402107,"FormularyType":"OHP","DrugName":"GA-1 ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001622"},{"Id":402108,"FormularyType":"OHP","DrugName":"MMA/PA ANAMI POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001623"},{"Id":402109,"FormularyType":"OHP","DrugName":"IVA ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001625"},{"Id":402110,"FormularyType":"OHP","DrugName":"HCU ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001626"},{"Id":402111,"FormularyType":"OHP","DrugName":"MSUD ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735001627"},{"Id":402112,"FormularyType":"OHP","DrugName":"NEOCATE SPLA LIQ JR VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735010059"},{"Id":402113,"FormularyType":"OHP","DrugName":"KETOCAL 4.1 LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735010060"},{"Id":402114,"FormularyType":"OHP","DrugName":"NEOCATE SYNE POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010099"},{"Id":402115,"FormularyType":"OHP","DrugName":"MSUD AID POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010143"},{"Id":402116,"FormularyType":"OHP","DrugName":"PKU PERIFLEX POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010164"},{"Id":402117,"FormularyType":"OHP","DrugName":"MSUD ANAMIX POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010168"},{"Id":402118,"FormularyType":"OHP","DrugName":"HCU ANAMIX POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010169"},{"Id":402119,"FormularyType":"OHP","DrugName":"PHENYLD GMP POW DHA/FIBR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010172"},{"Id":402120,"FormularyType":"OHP","DrugName":"PHENYLADE POW GMP","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010173"},{"Id":402121,"FormularyType":"OHP","DrugName":"COMPLEX ESSE POW MSD","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010175"},{"Id":402122,"FormularyType":"OHP","DrugName":"PHENYLADE60 POW DRNK MIX","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010177"},{"Id":402123,"FormularyType":"OHP","DrugName":"PHENYLADE60 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010178"},{"Id":402124,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010179"},{"Id":402125,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010180"},{"Id":402126,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010181"},{"Id":402127,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010182"},{"Id":402128,"FormularyType":"OHP","DrugName":"PHENYLADE POW ESSNTL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010183"},{"Id":402129,"FormularyType":"OHP","DrugName":"PHENYLD GMP POW DHA/FIBR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010196"},{"Id":402130,"FormularyType":"OHP","DrugName":"IVA ANAMIX POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010211"},{"Id":402131,"FormularyType":"OHP","DrugName":"MMA/PA ANAMI POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010215"},{"Id":402132,"FormularyType":"OHP","DrugName":"GA-1 ANAMIX POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010217"},{"Id":402133,"FormularyType":"OHP","DrugName":"TYR ANAMIX POW ERLY YRS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010218"},{"Id":402134,"FormularyType":"OHP","DrugName":"METHIONAID POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010242"},{"Id":402135,"FormularyType":"OHP","DrugName":"NEOCATE JR POW PREBIOTC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735010627"},{"Id":402136,"FormularyType":"OHP","DrugName":"EO28 SPLASH LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735011050"},{"Id":402137,"FormularyType":"OHP","DrugName":"POLYCAL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011152"},{"Id":402138,"FormularyType":"OHP","DrugName":"XMET XCYS POW MAXAMAID","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011457"},{"Id":402139,"FormularyType":"OHP","DrugName":"PKU PERIFLEX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011618"},{"Id":402140,"FormularyType":"OHP","DrugName":"TYR ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011619"},{"Id":402141,"FormularyType":"OHP","DrugName":"GA-1 ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011622"},{"Id":402142,"FormularyType":"OHP","DrugName":"MMA/PA ANAMI POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011623"},{"Id":402143,"FormularyType":"OHP","DrugName":"IVA ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011625"},{"Id":402144,"FormularyType":"OHP","DrugName":"HCU ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011626"},{"Id":402145,"FormularyType":"OHP","DrugName":"MSUD ANAMIX POW EARLY YR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011627"},{"Id":402146,"FormularyType":"OHP","DrugName":"NEOCATE JR POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735011790"},{"Id":402147,"FormularyType":"OHP","DrugName":"NEOCATE POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735012124"},{"Id":402148,"FormularyType":"OHP","DrugName":"NEOCATE SPLA LIQ JR GRAPE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735012435"},{"Id":402149,"FormularyType":"OHP","DrugName":"NEOCATE SPLA LIQ JR OR/PN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735012436"},{"Id":402150,"FormularyType":"OHP","DrugName":"NEOCATE SPLA LIQ JR FRUIT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735012437"},{"Id":402151,"FormularyType":"OHP","DrugName":"NEOCATE INFT POW DHA/ARA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735012595"},{"Id":402152,"FormularyType":"OHP","DrugName":"EO28 SPLASH LIQ TROPICAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735012666"},{"Id":402153,"FormularyType":"OHP","DrugName":"EO28 SPLASH LIQ GRAPE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735012670"},{"Id":402154,"FormularyType":"OHP","DrugName":"NEOCATE JR POW PREBIOTC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735012690"},{"Id":402155,"FormularyType":"OHP","DrugName":"NEOCATE JR POW PREBIOTC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735012912"},{"Id":402156,"FormularyType":"OHP","DrugName":"KETOCAL 4.1 LIQ LQ/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735013054"},{"Id":402157,"FormularyType":"OHP","DrugName":"NEOCATE SPLA LIQ JR UNFLV","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735014451"},{"Id":402158,"FormularyType":"OHP","DrugName":"PKU LOPHLEX LIQ LQ 20","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735015096"},{"Id":402159,"FormularyType":"OHP","DrugName":"PHENYLADE POW GMP","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735015426"},{"Id":402160,"FormularyType":"OHP","DrugName":"MONOGEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735016033"},{"Id":402161,"FormularyType":"OHP","DrugName":"PKU LOPHLEX LIQ LQ 20","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735016129"},{"Id":402162,"FormularyType":"OHP","DrugName":"PKU LOPHLEX LIQ LQ 20","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735016130"},{"Id":402163,"FormularyType":"OHP","DrugName":"NEOCATE JR POW PREBIOTC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735016456"},{"Id":402164,"FormularyType":"OHP","DrugName":"KETOCAL 4:1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735016670"},{"Id":402165,"FormularyType":"OHP","DrugName":"KETOCAL 3:1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735016672"},{"Id":402166,"FormularyType":"OHP","DrugName":"NEOCATE POW SPOON","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735016739"},{"Id":402167,"FormularyType":"OHP","DrugName":"HCU LOPHLEX LIQ LQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735016748"},{"Id":402168,"FormularyType":"OHP","DrugName":"MSUD LOPHLEX LIQ LQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735016749"},{"Id":402169,"FormularyType":"OHP","DrugName":"TYR LOPHLEX LIQ LQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735016750"},{"Id":402170,"FormularyType":"OHP","DrugName":"PHENYLADE POW GMP","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735016832"},{"Id":402171,"FormularyType":"OHP","DrugName":"KETOCAL 3:1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017155"},{"Id":402172,"FormularyType":"OHP","DrugName":"KETOCAL LIQ 2.5:1 LQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735017246"},{"Id":402173,"FormularyType":"OHP","DrugName":"MMA/PA MAXAM POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017779"},{"Id":402174,"FormularyType":"OHP","DrugName":"XLYS-XTRP POW MAXAMAID","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017780"},{"Id":402175,"FormularyType":"OHP","DrugName":"MSUD MAXAMAD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017781"},{"Id":402176,"FormularyType":"OHP","DrugName":"XMTVI MAXAMD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017785"},{"Id":402177,"FormularyType":"OHP","DrugName":"XPHE-XTYR POW MAXAMAID","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017786"},{"Id":402178,"FormularyType":"OHP","DrugName":"XMET MAXAMAD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017787"},{"Id":402179,"FormularyType":"OHP","DrugName":"XLYS-XTRP POW MAXAMUM","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017788"},{"Id":402180,"FormularyType":"OHP","DrugName":"MSUD MAXAMUM POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017789"},{"Id":402181,"FormularyType":"OHP","DrugName":"IVA MAXAMUM POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017790"},{"Id":402182,"FormularyType":"OHP","DrugName":"XLEU MAXAMAD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017791"},{"Id":402183,"FormularyType":"OHP","DrugName":"XPHE MAXAMAD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017792"},{"Id":402184,"FormularyType":"OHP","DrugName":"XPHE MAXAMAD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017793"},{"Id":402185,"FormularyType":"OHP","DrugName":"XPHE MAXAMAD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017794"},{"Id":402186,"FormularyType":"OHP","DrugName":"HCU MAXAMUM POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735017795"},{"Id":402187,"FormularyType":"OHP","DrugName":"DUOCAL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018262"},{"Id":402188,"FormularyType":"OHP","DrugName":"PERIFLEX POW ADVANCE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018305"},{"Id":402189,"FormularyType":"OHP","DrugName":"PERIFLEX POW ADVANCE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018306"},{"Id":402190,"FormularyType":"OHP","DrugName":"PERIFLEX POW ADVANCE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018307"},{"Id":402191,"FormularyType":"OHP","DrugName":"PERIFLEX POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018308"},{"Id":402192,"FormularyType":"OHP","DrugName":"PERIFLEX POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018309"},{"Id":402193,"FormularyType":"OHP","DrugName":"PERIFLEX POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018310"},{"Id":402194,"FormularyType":"OHP","DrugName":"KETOCAL 4.1 LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735018796"},{"Id":402195,"FormularyType":"OHP","DrugName":"ACERFLEX POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735018842"},{"Id":402196,"FormularyType":"OHP","DrugName":"UCD ANAMIX POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019292"},{"Id":402197,"FormularyType":"OHP","DrugName":"UCD ANAMIX POW JUNIOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019293"},{"Id":402198,"FormularyType":"OHP","DrugName":"HCU ANAMIX POW NEXT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019470"},{"Id":402199,"FormularyType":"OHP","DrugName":"IVA ANAMIX POW NEXT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019471"},{"Id":402200,"FormularyType":"OHP","DrugName":"MMA/PA ANAMX POW NEXT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019472"},{"Id":402201,"FormularyType":"OHP","DrugName":"PERIFLEX JUN POW PLUS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019474"},{"Id":402202,"FormularyType":"OHP","DrugName":"PERIFLEX JUN POW PLUS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019476"},{"Id":402203,"FormularyType":"OHP","DrugName":"PERIFLEX JUN POW PLUS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019477"},{"Id":402204,"FormularyType":"OHP","DrugName":"PERIFLEX JUN POW PLUS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019478"},{"Id":402205,"FormularyType":"OHP","DrugName":"TYR ANAMIX POW NEXT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735019479"},{"Id":402206,"FormularyType":"OHP","DrugName":"LOPHLEX LQ LIQ 20","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735019535"},{"Id":402207,"FormularyType":"OHP","DrugName":"PHENYLADE LIQ GMP READ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"49735019686"},{"Id":402208,"FormularyType":"OHP","DrugName":"MONOGEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"49735060339"},{"Id":402209,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"49884000702"},{"Id":402210,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"49884000901"},{"Id":402211,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"49884000910"},{"Id":402212,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"49884002001"},{"Id":402213,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"49884002010"},{"Id":402214,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"49884002101"},{"Id":402215,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"49884002110"},{"Id":402216,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"49884002201"},{"Id":402217,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"49884002210"},{"Id":402218,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107020","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","NDC":"49884004801"},{"Id":402219,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107030","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","NDC":"49884004901"},{"Id":402220,"FormularyType":"OHP","DrugName":"AMILORIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500010100305","GenericName":"AMILORIDE HCL TAB 5 MG","NDC":"49884011701"},{"Id":402221,"FormularyType":"OHP","DrugName":"AMILORIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500010100305","GenericName":"AMILORIDE HCL TAB 5 MG","NDC":"49884011710"},{"Id":402222,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"49884011952"},{"Id":402223,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"49884011991"},{"Id":402224,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"49884012301"},{"Id":402225,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"49884012305"},{"Id":402226,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"49884012401"},{"Id":402227,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"49884012552"},{"Id":402228,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"49884012591"},{"Id":402229,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"49884012752"},{"Id":402230,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"49884012791"},{"Id":402231,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"49884015576"},{"Id":402232,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"49884015676"},{"Id":402233,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"49884015802"},{"Id":402234,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"49884015852"},{"Id":402235,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"49884015902"},{"Id":402236,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"49884015952"},{"Id":402237,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"49884016002"},{"Id":402238,"FormularyType":"OHP","DrugName":"CALCITONIN SPR 200/ACT","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30043020002080","GenericName":"CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT","NDC":"49884016111"},{"Id":402239,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"49884017101"},{"Id":402240,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"49884017111"},{"Id":402241,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107040","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","NDC":"49884024801"},{"Id":402242,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000305","GenericName":"MINOXIDIL TAB 2.5 MG","NDC":"49884025601"},{"Id":402243,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000310","GenericName":"MINOXIDIL TAB 10 MG","NDC":"49884025701"},{"Id":402244,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000310","GenericName":"MINOXIDIL TAB 10 MG","NDC":"49884025705"},{"Id":402245,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"49884028302"},{"Id":402246,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"49884028352"},{"Id":402247,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107045","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","NDC":"49884033301"},{"Id":402248,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 35MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107055","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","NDC":"49884033901"},{"Id":402249,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"49884035803"},{"Id":402250,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"49884035852"},{"Id":402251,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100105","GenericName":"DANTROLENE SODIUM CAP 25 MG","NDC":"49884036201"},{"Id":402252,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100110","GenericName":"DANTROLENE SODIUM CAP 50 MG","NDC":"49884036301"},{"Id":402253,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100115","GenericName":"DANTROLENE SODIUM CAP 100 MG","NDC":"49884036401"},{"Id":402254,"FormularyType":"OHP","DrugName":"URSODIOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000325","GenericName":"URSODIOL TAB 250 MG","NDC":"49884041201"},{"Id":402255,"FormularyType":"OHP","DrugName":"URSODIOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000350","GenericName":"URSODIOL TAB 500 MG","NDC":"49884041301"},{"Id":402256,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107035","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","NDC":"49884042801"},{"Id":402257,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107050","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","NDC":"49884043001"},{"Id":402258,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"49884046564"},{"Id":402259,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"49884046565"},{"Id":402260,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"49884046566"},{"Id":402261,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"49884046663"},{"Id":402262,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"49884046665"},{"Id":402263,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"49884046667"},{"Id":402264,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 40MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107060","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 40 MG","NDC":"49884054601"},{"Id":402265,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"49884065909"},{"Id":402266,"FormularyType":"OHP","DrugName":"SAPROPTERIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565100320","GenericName":"SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG","NDC":"49884072008"},{"Id":402267,"FormularyType":"OHP","DrugName":"HYDROXYUREA CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700030000105","GenericName":"HYDROXYUREA CAP 500 MG","NDC":"49884072401"},{"Id":402268,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"49884076852"},{"Id":402269,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"49884076854"},{"Id":402270,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"49884077052"},{"Id":402271,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"49884077054"},{"Id":402272,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"49884081401"},{"Id":402273,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"49884084901"},{"Id":402274,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"49884087352"},{"Id":402275,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"49884087372"},{"Id":402276,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"49884087401"},{"Id":402277,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"49884094499"},{"Id":402278,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"49884094852"},{"Id":402279,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"49884094872"},{"Id":402280,"FormularyType":"OHP","DrugName":"CARNATION LIQ BREAKFAS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50000041516"},{"Id":402281,"FormularyType":"OHP","DrugName":"CARNATION LIQ BREAKFAS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50000041518"},{"Id":402282,"FormularyType":"OHP","DrugName":"CARNATION LIQ BREAKFAS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50000041568"},{"Id":402283,"FormularyType":"OHP","DrugName":"CARNATION LIQ BREAKFAS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50000041570"},{"Id":402284,"FormularyType":"OHP","DrugName":"CARNATION LIQ BREAKFAS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50000041578"},{"Id":402285,"FormularyType":"OHP","DrugName":"CARNATION LIQ BREAKFAS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50000041580"},{"Id":402286,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080500"},{"Id":402287,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL ORANGE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080501"},{"Id":402288,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080502"},{"Id":402289,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL LEM/LIME","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080503"},{"Id":402290,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL PREMAX","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080504"},{"Id":402291,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL PREMAX","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080505"},{"Id":402292,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL PREMAX","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080506"},{"Id":402293,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080508"},{"Id":402294,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080509"},{"Id":402295,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080510"},{"Id":402296,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL LEMONADE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080547"},{"Id":402297,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080558"},{"Id":402298,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080559"},{"Id":402299,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080560"},{"Id":402300,"FormularyType":"OHP","DrugName":"KINDRSPR PRO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50001080565"},{"Id":402301,"FormularyType":"OHP","DrugName":"KINDRSPR PRO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50001080566"},{"Id":402302,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50001080569"},{"Id":402303,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50001080572"},{"Id":402304,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL STRWBRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080577"},{"Id":402305,"FormularyType":"OHP","DrugName":"KINDERLYTE SOL STRWBRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50001080580"},{"Id":402306,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"50002086002"},{"Id":402307,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50002086003"},{"Id":402308,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50002086004"},{"Id":402309,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50002086005"},{"Id":402310,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50002086019"},{"Id":402311,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50002086020"},{"Id":402312,"FormularyType":"OHP","DrugName":"PEAK FLOW MIS METER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"50002086038"},{"Id":402313,"FormularyType":"OHP","DrugName":"HOLD CHAMBER MIS SMALL","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50002086045"},{"Id":402314,"FormularyType":"OHP","DrugName":"HOLD CHAMBER MIS MEDIUM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50002086046"},{"Id":402315,"FormularyType":"OHP","DrugName":"HOLD CHAMBER MIS ADLT LG","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50002086047"},{"Id":402316,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50002086054"},{"Id":402317,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"50002086070"},{"Id":402318,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50002086071"},{"Id":402319,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"50002086072"},{"Id":402320,"FormularyType":"OHP","DrugName":"DEFLUX NEEDL MIS 23X350MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236380","GenericName":"NEEDLE (DISP) 23 X 14\" (350 MM)","NDC":"50004072502"},{"Id":402321,"FormularyType":"OHP","DrugName":"PRENATAL CAP COMPLETE","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512082000120","GenericName":"*PRENAT-FE BISGLYC-METHYLF-FISH OIL CAP 9-0.267-191.67 MG***","NDC":"50008056005"},{"Id":402322,"FormularyType":"OHP","DrugName":"CARESTART KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50010022431"},{"Id":402323,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50011083304"},{"Id":402324,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"50011083326"},{"Id":402325,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50011083342"},{"Id":402326,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"50011083343"},{"Id":402327,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"50011083348"},{"Id":402328,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"50011083355"},{"Id":402329,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50011083357"},{"Id":402330,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"50011083358"},{"Id":402331,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50011083366"},{"Id":402332,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"50011083368"},{"Id":402333,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50011083369"},{"Id":402334,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"50011083375"},{"Id":402335,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"50011083376"},{"Id":402336,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50011083377"},{"Id":402337,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"50011083378"},{"Id":402338,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50011083379"},{"Id":402339,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50011083384"},{"Id":402340,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"50011083385"},{"Id":402341,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50011083386"},{"Id":402342,"FormularyType":"OHP","DrugName":"VERIFINE PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50011083387"},{"Id":402343,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"50011083388"},{"Id":402344,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"50011083389"},{"Id":402345,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"50011083390"},{"Id":402346,"FormularyType":"OHP","DrugName":"LIL MIXINS POW PEANUT","DosageForm":"POWD - Powder","Strength":"5","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50016091804"},{"Id":402347,"FormularyType":"OHP","DrugName":"LIL MIXINS POW EGG","DosageForm":"POWD - Powder","Strength":"5","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50016091817"},{"Id":402348,"FormularyType":"OHP","DrugName":"ENCALA POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50018070800"},{"Id":402349,"FormularyType":"OHP","DrugName":"ELLUME COV19 KIT HOME TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50021086001"},{"Id":402350,"FormularyType":"OHP","DrugName":"PIXEL COVID KIT HOME TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024306400","GenericName":"COVID-19 HOME COLLECTION TEST KIT","NDC":"50024092400"},{"Id":402351,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"50027049400"},{"Id":402352,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"50027049401"},{"Id":402353,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"50027049402"},{"Id":402354,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"50027049403"},{"Id":402355,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"50027049404"},{"Id":402356,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"50027049405"},{"Id":402357,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50027049406"},{"Id":402358,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50027049407"},{"Id":402359,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50027049408"},{"Id":402360,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50027049409"},{"Id":402361,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50027049410"},{"Id":402362,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/32G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906343","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X 5/16\"","NDC":"50027049411"},{"Id":402363,"FormularyType":"OHP","DrugName":"TRUE COMFORT PAD PRO","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50027049412"},{"Id":402364,"FormularyType":"OHP","DrugName":"INSULIN SRYG MIS 1ML/32G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906344","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16\"","NDC":"50027049414"},{"Id":402365,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"50027049415"},{"Id":402366,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"50027049416"},{"Id":402367,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"50027049417"},{"Id":402368,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"50027049418"},{"Id":402369,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS SPACER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50027049441"},{"Id":402370,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50027049442"},{"Id":402371,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50027049443"},{"Id":402372,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50027049444"},{"Id":402373,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"50027049465"},{"Id":402374,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906341","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/2\"","NDC":"50027049466"},{"Id":402375,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"50027049486"},{"Id":402376,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"50027049487"},{"Id":402377,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"50027049488"},{"Id":402378,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"50027049489"},{"Id":402379,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50027049490"},{"Id":402380,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50027049491"},{"Id":402381,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/32G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906344","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16\"","NDC":"50027049492"},{"Id":402382,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50035061501"},{"Id":402383,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"50035061503"},{"Id":402384,"FormularyType":"OHP","DrugName":"MODD1 PATIEN KIT WELCOME","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"20","AgeMaxUnit":"Y","GenericProductIdentifier":"97201030506400","GenericName":"*INSULIN INFUSION DISPOSABLE PUMP KIT***","NDC":"50037080612"},{"Id":402385,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50039085944"},{"Id":402386,"FormularyType":"OHP","DrugName":"GOTOKNOW KIT ANTIGEN","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50042003715"},{"Id":402387,"FormularyType":"OHP","DrugName":"COVID-19 AG KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50042055907"},{"Id":402388,"FormularyType":"OHP","DrugName":"COVID-19 AG KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50042055908"},{"Id":402389,"FormularyType":"OHP","DrugName":"COVID-19 AG KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50042055909"},{"Id":402390,"FormularyType":"OHP","DrugName":"COVID-19 AG KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50042055912"},{"Id":402391,"FormularyType":"OHP","DrugName":"COVID-19 KIT SELF TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50052033540"},{"Id":402392,"FormularyType":"OHP","DrugName":"COVID-19 KIT SELF TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50052033543"},{"Id":402393,"FormularyType":"OHP","DrugName":"CHICKEN/PEAS POW CARROTS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50052082404"},{"Id":402394,"FormularyType":"OHP","DrugName":"KALE/QUINOA POW BERRIES","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50052082405"},{"Id":402395,"FormularyType":"OHP","DrugName":"CHICKEN/PEAS POW PEDIATRI","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50052082408"},{"Id":402396,"FormularyType":"OHP","DrugName":"KALE/QUINOA POW PEDIATRI","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50052082409"},{"Id":402397,"FormularyType":"OHP","DrugName":"TRUE COMFORT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50058086400"},{"Id":402398,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50058086401"},{"Id":402399,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50058086402"},{"Id":402400,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"50058086403"},{"Id":402401,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"50058086404"},{"Id":402402,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50058086405"},{"Id":402403,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50058086406"},{"Id":402404,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50058086410"},{"Id":402405,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 29GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146316","GenericName":"INSULIN PEN NEEDLE 29 G X 4 MM (1/6\" OR 5/32\")","NDC":"50058086413"},{"Id":402406,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 29GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146318","GenericName":"INSULIN PEN NEEDLE 29 G X 5 MM (1/5\" OR 3/16\")","NDC":"50058086414"},{"Id":402407,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906382","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 5/16\"","NDC":"50058086415"},{"Id":402408,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906326","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 5/16\"","NDC":"50058086416"},{"Id":402409,"FormularyType":"OHP","DrugName":"PRO COMFORT PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50058086428"},{"Id":402410,"FormularyType":"OHP","DrugName":"PKU EASY POW SHAKE&GO","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50059034108"},{"Id":402411,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"50062021812"},{"Id":402412,"FormularyType":"OHP","DrugName":"VERISAFE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"50062021815"},{"Id":402413,"FormularyType":"OHP","DrugName":"VERISAFE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"50062021816"},{"Id":402414,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"50062021823"},{"Id":402415,"FormularyType":"OHP","DrugName":"PEAK FLOW MIS METER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"50070097943"},{"Id":402416,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50071076500"},{"Id":402417,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50071076501"},{"Id":402418,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50071076502"},{"Id":402419,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50071076505"},{"Id":402420,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/32G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906344","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16\"","NDC":"50071076509"},{"Id":402421,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50071076510"},{"Id":402422,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50071076511"},{"Id":402423,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50071076512"},{"Id":402424,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"50071076513"},{"Id":402425,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"50078095504"},{"Id":402426,"FormularyType":"OHP","DrugName":"MELATONIN CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000140","GenericName":"MELATONIN CAP 3 MG","NDC":"50078095513"},{"Id":402427,"FormularyType":"OHP","DrugName":"MELATONIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000150","GenericName":"MELATONIN CAP 5 MG","NDC":"50078095514"},{"Id":402428,"FormularyType":"OHP","DrugName":"LYZA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102010001"},{"Id":402429,"FormularyType":"OHP","DrugName":"LYZA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102010003"},{"Id":402430,"FormularyType":"OHP","DrugName":"LYZA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102010010"},{"Id":402431,"FormularyType":"OHP","DrugName":"LYZA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102010048"},{"Id":402432,"FormularyType":"OHP","DrugName":"ECONTRA OS TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"50102021111"},{"Id":402433,"FormularyType":"OHP","DrugName":"ECONTRA OS TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"50102021113"},{"Id":402434,"FormularyType":"OHP","DrugName":"AUBRA EQ TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"50102022021"},{"Id":402435,"FormularyType":"OHP","DrugName":"AUBRA EQ TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"50102022023"},{"Id":402436,"FormularyType":"OHP","DrugName":"TARINA 24 FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"50102022421"},{"Id":402437,"FormularyType":"OHP","DrugName":"TARINA 24 FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"50102022423"},{"Id":402438,"FormularyType":"OHP","DrugName":"TARINA FE TAB 1/20 EQ","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"50102022821"},{"Id":402439,"FormularyType":"OHP","DrugName":"TARINA FE TAB 1/20 EQ","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"50102022823"},{"Id":402440,"FormularyType":"OHP","DrugName":"CHATEAL EQ TAB 0.15/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"50102023021"},{"Id":402441,"FormularyType":"OHP","DrugName":"CHATEAL EQ TAB 0.15/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"50102023023"},{"Id":402442,"FormularyType":"OHP","DrugName":"TRI-VYLIBRA TAB LO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"50102023101"},{"Id":402443,"FormularyType":"OHP","DrugName":"TRI-VYLIBRA TAB LO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"50102023111"},{"Id":402444,"FormularyType":"OHP","DrugName":"TRI-VYLIBRA TAB LO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"50102023113"},{"Id":402445,"FormularyType":"OHP","DrugName":"TRI-VYLIBRA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"50102023311"},{"Id":402446,"FormularyType":"OHP","DrugName":"TRI-VYLIBRA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"50102023313"},{"Id":402447,"FormularyType":"OHP","DrugName":"VYLIBRA TAB 0.25-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"50102023511"},{"Id":402448,"FormularyType":"OHP","DrugName":"VYLIBRA TAB 0.25-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"50102023513"},{"Id":402449,"FormularyType":"OHP","DrugName":"JASMIEL TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"50102024021"},{"Id":402450,"FormularyType":"OHP","DrugName":"JASMIEL TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"50102024023"},{"Id":402451,"FormularyType":"OHP","DrugName":"CYRED EQ TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"50102025421"},{"Id":402452,"FormularyType":"OHP","DrugName":"CYRED EQ TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"50102025423"},{"Id":402453,"FormularyType":"OHP","DrugName":"LYLEQ TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102030001"},{"Id":402454,"FormularyType":"OHP","DrugName":"LYLEQ TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102030011"},{"Id":402455,"FormularyType":"OHP","DrugName":"LYLEQ TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"50102030013"},{"Id":402456,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"50111032701"},{"Id":402457,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"50111032703"},{"Id":402458,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"50111032801"},{"Id":402459,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"50111032803"},{"Id":402460,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"50111033301"},{"Id":402461,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"50111033302"},{"Id":402462,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"50111033306"},{"Id":402463,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"50111033401"},{"Id":402464,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"50111033402"},{"Id":402465,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"50111039701"},{"Id":402466,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"50111039801"},{"Id":402467,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"50111039803"},{"Id":402468,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"50111045601"},{"Id":402469,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"50111045602"},{"Id":402470,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"50111045603"},{"Id":402471,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"50111078710"},{"Id":402472,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"50111078751"},{"Id":402473,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"50111078766"},{"Id":402474,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"50111078810"},{"Id":402475,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"50111078855"},{"Id":402476,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"50111078867"},{"Id":402477,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000340","GenericName":"AZITHROMYCIN TAB 600 MG","NDC":"50111078910"},{"Id":402478,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"50111091501"},{"Id":402479,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"50111091601"},{"Id":402480,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"50111091701"},{"Id":402481,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"50111091703"},{"Id":402482,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"50111091801"},{"Id":402483,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 7%","DosageForm":"NEBU - Nebulization solution","Strength":"7","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002535","GenericName":"SODIUM CHLORIDE SOLN NEBU 7%","NDC":"50190014123"},{"Id":402484,"FormularyType":"OHP","DrugName":"GORDONS UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"50217000168"},{"Id":402485,"FormularyType":"OHP","DrugName":"ADBRY INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027308045E520","GenericName":"TRALOKINUMAB-LDRM SUBCUTANEOUS SOLN PREFILLED SYR 150 MG/ML","NDC":"50222034602"},{"Id":402486,"FormularyType":"OHP","DrugName":"ADBRY INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027308045E520","GenericName":"TRALOKINUMAB-LDRM SUBCUTANEOUS SOLN PREFILLED SYR 150 MG/ML","NDC":"50222034604"},{"Id":402487,"FormularyType":"OHP","DrugName":"ADBRY INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027308045D530","GenericName":"TRALOKINUMAB-LDRM SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"50222035001"},{"Id":402488,"FormularyType":"OHP","DrugName":"ADBRY INJ 300/2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"300","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ECZEMA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9027308045D530","GenericName":"TRALOKINUMAB-LDRM SUBCUTANEOUS SOLN AUTO-INJECTOR 300 MG/2ML","NDC":"50222035002"},{"Id":402489,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"50228010501"},{"Id":402490,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"50228010505"},{"Id":402491,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"50228010510"},{"Id":402492,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"50228010530"},{"Id":402493,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"50228010601"},{"Id":402494,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"50228010605"},{"Id":402495,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"50228010630"},{"Id":402496,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"50228010701"},{"Id":402497,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"50228010705"},{"Id":402498,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"50228010710"},{"Id":402499,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"50228010730"},{"Id":402500,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"50228011605"},{"Id":402501,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"50228011610"},{"Id":402502,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"50228011690"},{"Id":402503,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"50228011705"},{"Id":402504,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"50228011710"},{"Id":402505,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"50228011790"},{"Id":402506,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"50228011805"},{"Id":402507,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"50228011810"},{"Id":402508,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"50228011890"},{"Id":402509,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"50228011905"},{"Id":402510,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"50228011910"},{"Id":402511,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"50228011930"},{"Id":402512,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"50228011990"},{"Id":402513,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"50228012405"},{"Id":402514,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"50228012410"},{"Id":402515,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"50228012430"},{"Id":402516,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"50228012490"},{"Id":402517,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"50228012610"},{"Id":402518,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"50228012710"},{"Id":402519,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"50228012810"},{"Id":402520,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"50228012990"},{"Id":402521,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"50228013010"},{"Id":402522,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"50228013190"},{"Id":402523,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"50228014601"},{"Id":402524,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"50228014605"},{"Id":402525,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"50228014610"},{"Id":402526,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"50228015701"},{"Id":402527,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"50228015705"},{"Id":402528,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"50228015801"},{"Id":402529,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"50228015805"},{"Id":402530,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"50228017701"},{"Id":402531,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"50228017705"},{"Id":402532,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"50228017801"},{"Id":402533,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"50228017805"},{"Id":402534,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"50228017901"},{"Id":402535,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"50228017905"},{"Id":402536,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"50228017910"},{"Id":402537,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"50228018001"},{"Id":402538,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"50228018005"},{"Id":402539,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"50228018010"},{"Id":402540,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"50228018101"},{"Id":402541,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"50228018105"},{"Id":402542,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"50228018201"},{"Id":402543,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"50228018210"},{"Id":402544,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"50228018301"},{"Id":402545,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"50228018310"},{"Id":402546,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"50228018401"},{"Id":402547,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"50228018410"},{"Id":402548,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"50228018501"},{"Id":402549,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007520","GenericName":"LEVETIRACETAM TAB ER 24HR 500 MG","NDC":"50228018960"},{"Id":402550,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"50228019060"},{"Id":402551,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"50228019260"},{"Id":402552,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"50228019360"},{"Id":402553,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"50228019460"},{"Id":402554,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"50228019560"},{"Id":402555,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"50228022501"},{"Id":402556,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"50228022510"},{"Id":402557,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"50228022601"},{"Id":402558,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"50228022610"},{"Id":402559,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"50228022701"},{"Id":402560,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"50228022710"},{"Id":402561,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"50228022801"},{"Id":402562,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"50228022810"},{"Id":402563,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"50228022901"},{"Id":402564,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"50228022910"},{"Id":402565,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"50228023001"},{"Id":402566,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"50228023010"},{"Id":402567,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"50228023101"},{"Id":402568,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"50228023110"},{"Id":402569,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"50228023201"},{"Id":402570,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"50228023205"},{"Id":402571,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"50228023301"},{"Id":402572,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"50228023305"},{"Id":402573,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"50228023310"},{"Id":402574,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"50228033910"},{"Id":402575,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"50228033930"},{"Id":402576,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"50228033990"},{"Id":402577,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"50228034010"},{"Id":402578,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"50228034030"},{"Id":402579,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"50228034090"},{"Id":402580,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"50228034110"},{"Id":402581,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"50228034130"},{"Id":402582,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"50228034190"},{"Id":402583,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"50228035090"},{"Id":402584,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"50228035190"},{"Id":402585,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"50228035290"},{"Id":402586,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"50228035390"},{"Id":402587,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"50228035490"},{"Id":402588,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"50228035590"},{"Id":402589,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"50228035690"},{"Id":402590,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"50228035790"},{"Id":402591,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"50228037905"},{"Id":402592,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"50228037930"},{"Id":402593,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"50228037990"},{"Id":402594,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"50228042360"},{"Id":402595,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"50228042460"},{"Id":402596,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"50228042730"},{"Id":402597,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"50228042790"},{"Id":402598,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"50228042830"},{"Id":402599,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"50228042890"},{"Id":402600,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"50228043401"},{"Id":402601,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"50228043405"},{"Id":402602,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"50228043501"},{"Id":402603,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"50228043505"},{"Id":402604,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"50228043601"},{"Id":402605,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"50228043605"},{"Id":402606,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"50228045110"},{"Id":402607,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"50228045190"},{"Id":402608,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"50228045205"},{"Id":402609,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"50228045290"},{"Id":402610,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"50228045310"},{"Id":402611,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"50228045390"},{"Id":402612,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"50228045405"},{"Id":402613,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"50228045490"},{"Id":402614,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"50228045701"},{"Id":402615,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"50228045705"},{"Id":402616,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"50228045801"},{"Id":402617,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"50228045805"},{"Id":402618,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"50228045810"},{"Id":402619,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"50228045901"},{"Id":402620,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"50228045905"},{"Id":402621,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"50228046001"},{"Id":402622,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"50228046010"},{"Id":402623,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"50228046101"},{"Id":402624,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"50228046110"},{"Id":402625,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"50228046501"},{"Id":402626,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"50228046505"},{"Id":402627,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"50228046601"},{"Id":402628,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"50228046605"},{"Id":402629,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"50228047005"},{"Id":402630,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"50228047012"},{"Id":402631,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"50228047105"},{"Id":402632,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"50228047112"},{"Id":402633,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"50228047205"},{"Id":402634,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"50228047212"},{"Id":402635,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"50228047360"},{"Id":402636,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"50228048101"},{"Id":402637,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"50228048105"},{"Id":402638,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"50228048201"},{"Id":402639,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"50228048205"},{"Id":402640,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"50228048301"},{"Id":402641,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"50228048305"},{"Id":402642,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100320","GenericName":"DILTIAZEM HCL TAB 120 MG","NDC":"50228048401"},{"Id":402643,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"50228064505"},{"Id":402644,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"50228064590"},{"Id":402645,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"50228064605"},{"Id":402646,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"50228064690"},{"Id":402647,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"50228064705"},{"Id":402648,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"50228064790"},{"Id":402649,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"50228064805"},{"Id":402650,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"50228064890"},{"Id":402651,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"50228064905"},{"Id":402652,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"50228064990"},{"Id":402653,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"50228065005"},{"Id":402654,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"50228065090"},{"Id":402655,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"50228065105"},{"Id":402656,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"50228065190"},{"Id":402657,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"50228065205"},{"Id":402658,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"50228065290"},{"Id":402659,"FormularyType":"OHP","DrugName":"ENSPRYNG INJ","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9940507040E520","GenericName":"SATRALIZUMAB-MWGE SUBCUTANEOUS SOLN PREF SYRINGE 120 MG/ML","NDC":"50242000701"},{"Id":402660,"FormularyType":"OHP","DrugName":"NUTROPIN AQ INJ 10MG/2ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000D220","GenericName":"SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/2ML","NDC":"50242007401"},{"Id":402661,"FormularyType":"OHP","DrugName":"NUTROPIN AQ INJ NUSPIN 5","DosageForm":"SOPN - Soln Pen-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000D207","GenericName":"SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/2ML","NDC":"50242007501"},{"Id":402662,"FormularyType":"OHP","DrugName":"NUTROPIN AQ INJ 20MG/2ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3010002000D250","GenericName":"SOMATROPIN SOLUTION PEN-INJECTOR 20 MG/2ML","NDC":"50242007601"},{"Id":402663,"FormularyType":"OHP","DrugName":"ITOVEBI TAB 9MG","DosageForm":"TABS - Tablet","Strength":"9","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21538045000320","GenericName":"INAVOLISIB TAB 9 MG","NDC":"50242007908"},{"Id":402664,"FormularyType":"OHP","DrugName":"ITOVEBI TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21538045000310","GenericName":"INAVOLISIB TAB 3 MG","NDC":"50242008408"},{"Id":402665,"FormularyType":"OHP","DrugName":"ZELBORAF TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532080000320","GenericName":"VEMURAFENIB TAB 240 MG","NDC":"50242009002"},{"Id":402666,"FormularyType":"OHP","DrugName":"ROZLYTREK CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533820000120","GenericName":"ENTRECTINIB CAP 100 MG","NDC":"50242009130"},{"Id":402667,"FormularyType":"OHP","DrugName":"ROZLYTREK CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533820000130","GenericName":"ENTRECTINIB CAP 200 MG","NDC":"50242009490"},{"Id":402668,"FormularyType":"OHP","DrugName":"PULMOZYME SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45304020002010","GenericName":"DORNASE ALFA INHAL SOLN 2.5 MG/2.5ML","NDC":"50242010039"},{"Id":402669,"FormularyType":"OHP","DrugName":"PULMOZYME SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45304020002010","GenericName":"DORNASE ALFA INHAL SOLN 2.5 MG/2.5ML","NDC":"50242010040"},{"Id":402670,"FormularyType":"OHP","DrugName":"ALECENSA CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530507100120","GenericName":"ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT)","NDC":"50242013001"},{"Id":402671,"FormularyType":"OHP","DrugName":"ACTEMRA INJ 162/0.9","DosageForm":"SOSY - Soln Pref Syr","Strength":"162","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"INTERLEUKIN-6 RECEPTOR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6650007000E520","GenericName":"TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML","NDC":"50242013801"},{"Id":402672,"FormularyType":"OHP","DrugName":"ERIVEDGE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21370070000120","GenericName":"VISMODEGIB CAP 150 MG","NDC":"50242014001"},{"Id":402673,"FormularyType":"OHP","DrugName":"ACTEMRA INJ ACTPEN","DosageForm":"SOAJ - Soln Auto-inj","Strength":"162","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"INTERLEUKIN-6 RECEPTOR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6650007000D520","GenericName":"TOCILIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 162 MG/0.9ML","NDC":"50242014301"},{"Id":402674,"FormularyType":"OHP","DrugName":"XOLAIR INJ 75/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460306000E510","GenericName":"OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML","NDC":"50242021401"},{"Id":402675,"FormularyType":"OHP","DrugName":"XOLAIR INJ 75/0.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460306000E510","GenericName":"OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML","NDC":"50242021403"},{"Id":402676,"FormularyType":"OHP","DrugName":"XOLAIR INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460306000E520","GenericName":"OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML","NDC":"50242021503"},{"Id":402677,"FormularyType":"OHP","DrugName":"XOLAIR INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"ANTIASTHMATIC - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4460306000E520","GenericName":"OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML","NDC":"50242021586"},{"Id":402678,"FormularyType":"OHP","DrugName":"COTELLIC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533530200320","GenericName":"COBIMETINIB FUMARATE TAB 20 MG (BASE EQUIVALENT)","NDC":"50242071701"},{"Id":402679,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"50268003611"},{"Id":402680,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"50268003614"},{"Id":402681,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"50268018211"},{"Id":402682,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"50268018215"},{"Id":402683,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"50268018311"},{"Id":402684,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"50268018330"},{"Id":402685,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"50268020011"},{"Id":402686,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"50268020016"},{"Id":402687,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50268030811"},{"Id":402688,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50268030815"},{"Id":402689,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50268048911"},{"Id":402690,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50268048915"},{"Id":402691,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"50268049701"},{"Id":402692,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"50268049711"},{"Id":402693,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"50268049801"},{"Id":402694,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"50268049811"},{"Id":402695,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"50268049901"},{"Id":402696,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"50268049911"},{"Id":402697,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"50268050001"},{"Id":402698,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"50268050011"},{"Id":402699,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"50268050101"},{"Id":402700,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"50268050111"},{"Id":402701,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"50268055211"},{"Id":402702,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"50268055215"},{"Id":402703,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"50268055560"},{"Id":402704,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"50268064711"},{"Id":402705,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"50268064714"},{"Id":402706,"FormularyType":"OHP","DrugName":"PRENATAL TAB PLUS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"50268067701"},{"Id":402707,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"50268073124"},{"Id":402708,"FormularyType":"OHP","DrugName":"SODIUM FLUOR GEL 1.1%","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"50268073356"},{"Id":402709,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"50268074511"},{"Id":402710,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"50268074514"},{"Id":402711,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"50268087219"},{"Id":402712,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"50268087228"},{"Id":402713,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"50268087285"},{"Id":402714,"FormularyType":"OHP","DrugName":"STIVARGA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533050000320","GenericName":"REGORAFENIB TAB 40 MG","NDC":"50419017101"},{"Id":402715,"FormularyType":"OHP","DrugName":"STIVARGA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533050000320","GenericName":"REGORAFENIB TAB 40 MG","NDC":"50419017103"},{"Id":402716,"FormularyType":"OHP","DrugName":"STIVARGA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533050000320","GenericName":"REGORAFENIB TAB 40 MG","NDC":"50419017105"},{"Id":402717,"FormularyType":"OHP","DrugName":"STIVARGA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533050000320","GenericName":"REGORAFENIB TAB 40 MG","NDC":"50419017106"},{"Id":402718,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000310","GenericName":"RIOCIGUAT TAB 0.5 MG","NDC":"50419025001"},{"Id":402719,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000310","GenericName":"RIOCIGUAT TAB 0.5 MG","NDC":"50419025091"},{"Id":402720,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000320","GenericName":"RIOCIGUAT TAB 1 MG","NDC":"50419025101"},{"Id":402721,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000320","GenericName":"RIOCIGUAT TAB 1 MG","NDC":"50419025191"},{"Id":402722,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000330","GenericName":"RIOCIGUAT TAB 1.5 MG","NDC":"50419025201"},{"Id":402723,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000330","GenericName":"RIOCIGUAT TAB 1.5 MG","NDC":"50419025291"},{"Id":402724,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000340","GenericName":"RIOCIGUAT TAB 2 MG","NDC":"50419025301"},{"Id":402725,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000340","GenericName":"RIOCIGUAT TAB 2 MG","NDC":"50419025391"},{"Id":402726,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000350","GenericName":"RIOCIGUAT TAB 2.5 MG","NDC":"50419025401"},{"Id":402727,"FormularyType":"OHP","DrugName":"ADEMPAS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40134050000350","GenericName":"RIOCIGUAT TAB 2.5 MG","NDC":"50419025491"},{"Id":402728,"FormularyType":"OHP","DrugName":"VITRAKVI CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533835200120","GenericName":"LAROTRECTINIB SULFATE CAP 25 MG (BASE EQUIVALENT)","NDC":"50419039001"},{"Id":402729,"FormularyType":"OHP","DrugName":"VITRAKVI CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533835200150","GenericName":"LAROTRECTINIB SULFATE CAP 100 MG (BASE EQUIVALENT)","NDC":"50419039101"},{"Id":402730,"FormularyType":"OHP","DrugName":"VITRAKVI SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533835202020","GenericName":"LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT)","NDC":"50419039201"},{"Id":402731,"FormularyType":"OHP","DrugName":"VITRAKVI SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533835202020","GenericName":"LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT)","NDC":"50419039302"},{"Id":402732,"FormularyType":"OHP","DrugName":"VITRAKVI SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533835202020","GenericName":"LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT)","NDC":"50419039303"},{"Id":402733,"FormularyType":"OHP","DrugName":"NUBEQA TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402425000320","GenericName":"DAROLUTAMIDE TAB 300 MG","NDC":"50419039501"},{"Id":402734,"FormularyType":"OHP","DrugName":"HYRNUO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533057000315","GenericName":"SEVABERTINIB TAB 10 MG","NDC":"50419039701"},{"Id":402735,"FormularyType":"OHP","DrugName":"KERENDIA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000310","GenericName":"FINERENONE TAB 10 MG","NDC":"50419054001"},{"Id":402736,"FormularyType":"OHP","DrugName":"KERENDIA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000310","GenericName":"FINERENONE TAB 10 MG","NDC":"50419054002"},{"Id":402737,"FormularyType":"OHP","DrugName":"KERENDIA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000310","GenericName":"FINERENONE TAB 10 MG","NDC":"50419054005"},{"Id":402738,"FormularyType":"OHP","DrugName":"KERENDIA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000310","GenericName":"FINERENONE TAB 10 MG","NDC":"50419054006"},{"Id":402739,"FormularyType":"OHP","DrugName":"KERENDIA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000310","GenericName":"FINERENONE TAB 10 MG","NDC":"50419054070"},{"Id":402740,"FormularyType":"OHP","DrugName":"KERENDIA TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000320","GenericName":"FINERENONE TAB 20 MG","NDC":"50419054101"},{"Id":402741,"FormularyType":"OHP","DrugName":"KERENDIA TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000320","GenericName":"FINERENONE TAB 20 MG","NDC":"50419054102"},{"Id":402742,"FormularyType":"OHP","DrugName":"KERENDIA TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000320","GenericName":"FINERENONE TAB 20 MG","NDC":"50419054105"},{"Id":402743,"FormularyType":"OHP","DrugName":"KERENDIA TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000320","GenericName":"FINERENONE TAB 20 MG","NDC":"50419054106"},{"Id":402744,"FormularyType":"OHP","DrugName":"KERENDIA TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000320","GenericName":"FINERENONE TAB 20 MG","NDC":"50419054170"},{"Id":402745,"FormularyType":"OHP","DrugName":"KERENDIA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000330","GenericName":"FINERENONE TAB 40 MG","NDC":"50419054201"},{"Id":402746,"FormularyType":"OHP","DrugName":"KERENDIA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000330","GenericName":"FINERENONE TAB 40 MG","NDC":"50419054202"},{"Id":402747,"FormularyType":"OHP","DrugName":"KERENDIA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000330","GenericName":"FINERENONE TAB 40 MG","NDC":"50419054205"},{"Id":402748,"FormularyType":"OHP","DrugName":"KERENDIA TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"MINERALOCORTICOID RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30354030000330","GenericName":"FINERENONE TAB 40 MG","NDC":"50419054206"},{"Id":402749,"FormularyType":"OHP","DrugName":"LAMPIT TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400055000320","GenericName":"NIFURTIMOX TAB 30 MG","NDC":"50419075001"},{"Id":402750,"FormularyType":"OHP","DrugName":"LAMPIT TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400055000340","GenericName":"NIFURTIMOX TAB 120 MG","NDC":"50419075101"},{"Id":402751,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"50421000877"},{"Id":402752,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"50421000878"},{"Id":402753,"FormularyType":"OHP","DrugName":"SLOW RELEASE TAB 143MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"50428000313"},{"Id":402754,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"50428000696"},{"Id":402755,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"50428001004"},{"Id":402756,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"50428001170"},{"Id":402757,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"50428001769"},{"Id":402758,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"50428001777"},{"Id":402759,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"50428002662"},{"Id":402760,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"50428002824"},{"Id":402761,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428004212"},{"Id":402762,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"50428005345"},{"Id":402763,"FormularyType":"OHP","DrugName":"CVS FIBER CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"50428005484"},{"Id":402764,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50428007672"},{"Id":402765,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"50428008226"},{"Id":402766,"FormularyType":"OHP","DrugName":"CVS ITCH REL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"50428008517"},{"Id":402767,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428009061"},{"Id":402768,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428009065"},{"Id":402769,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428009256"},{"Id":402770,"FormularyType":"OHP","DrugName":"CVS FIBER CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"50428009259"},{"Id":402771,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428009264"},{"Id":402772,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428009265"},{"Id":402773,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428009624"},{"Id":402774,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428009834"},{"Id":402775,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428009835"},{"Id":402776,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428009836"},{"Id":402777,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428009837"},{"Id":402778,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"50428009980"},{"Id":402779,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"50428009981"},{"Id":402780,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"50428010060"},{"Id":402781,"FormularyType":"OHP","DrugName":"ALCOHOL WIPE MIS 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"50428012044"},{"Id":402782,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428014674"},{"Id":402783,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"50428014700"},{"Id":402784,"FormularyType":"OHP","DrugName":"ANTACID MAX CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"50428014730"},{"Id":402785,"FormularyType":"OHP","DrugName":"CVS MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428015052"},{"Id":402786,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB REL/RR","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428015060"},{"Id":402787,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300105","GenericName":"DOCUSATE SODIUM CAP 50 MG","NDC":"50428015168"},{"Id":402788,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300105","GenericName":"DOCUSATE SODIUM CAP 50 MG","NDC":"50428015169"},{"Id":402789,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"50428016051"},{"Id":402790,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428016064"},{"Id":402791,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428016527"},{"Id":402792,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428016528"},{"Id":402793,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428016530"},{"Id":402794,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG CINN","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428016534"},{"Id":402795,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"50428017236"},{"Id":402796,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"50428021100"},{"Id":402797,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"50428021103"},{"Id":402798,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"50428021963"},{"Id":402799,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"50428025036"},{"Id":402800,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428025147"},{"Id":402801,"FormularyType":"OHP","DrugName":"CVS MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428025204"},{"Id":402802,"FormularyType":"OHP","DrugName":"CVS ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"50428025409"},{"Id":402803,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"50428025563"},{"Id":402804,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428025603"},{"Id":402805,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428025610"},{"Id":402806,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"50428025773"},{"Id":402807,"FormularyType":"OHP","DrugName":"CORTISONE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"50428025901"},{"Id":402808,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"50428025949"},{"Id":402809,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"50428026016"},{"Id":402810,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428026413"},{"Id":402811,"FormularyType":"OHP","DrugName":"CVS SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"50428026496"},{"Id":402812,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50428026711"},{"Id":402813,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428026753"},{"Id":402814,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"50428026797"},{"Id":402815,"FormularyType":"OHP","DrugName":"CVS ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"50428026853"},{"Id":402816,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428026854"},{"Id":402817,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428026915"},{"Id":402818,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"50428026926"},{"Id":402819,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"50428026927"},{"Id":402820,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"50428027119"},{"Id":402821,"FormularyType":"OHP","DrugName":"CVS PRENATAL TAB 27-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"50428027137"},{"Id":402822,"FormularyType":"OHP","DrugName":"PRENATAL+DHA MIS WOMENS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006318","GenericName":"*PRENATAL W/FE FUM-FA TAB 28-0.975 MG & DHA CAP 200 MG PACK*","NDC":"50428027277"},{"Id":402823,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"50428027315"},{"Id":402824,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB CHLDRN","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"50428027426"},{"Id":402825,"FormularyType":"OHP","DrugName":"CVS PINWORM SUS 50MG/ML","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"50428027600"},{"Id":402826,"FormularyType":"OHP","DrugName":"ADHESIVE PAD 6\"X6\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"50428027642"},{"Id":402827,"FormularyType":"OHP","DrugName":"CVS VIT B12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"50428027646"},{"Id":402828,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"50428027684"},{"Id":402829,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428027709"},{"Id":402830,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428027781"},{"Id":402831,"FormularyType":"OHP","DrugName":"CVS SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"50428027915"},{"Id":402832,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"50428028011"},{"Id":402833,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"50428028015"},{"Id":402834,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428028092"},{"Id":402835,"FormularyType":"OHP","DrugName":"CVS D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"50428028110"},{"Id":402836,"FormularyType":"OHP","DrugName":"ALLERGY REL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428028156"},{"Id":402837,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428028167"},{"Id":402838,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428028226"},{"Id":402839,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428028235"},{"Id":402840,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428028360"},{"Id":402841,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428028552"},{"Id":402842,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428028600"},{"Id":402843,"FormularyType":"OHP","DrugName":"CVS CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100005000325","GenericName":"CALCIUM TAB 600 MG","NDC":"50428028724"},{"Id":402844,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428028756"},{"Id":402845,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428028922"},{"Id":402846,"FormularyType":"OHP","DrugName":"CVS B6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"50428028945"},{"Id":402847,"FormularyType":"OHP","DrugName":"CVS ALLERGY LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428029018"},{"Id":402848,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"50428029113"},{"Id":402849,"FormularyType":"OHP","DrugName":"CVS B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"50428029214"},{"Id":402850,"FormularyType":"OHP","DrugName":"CVS IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"50428029449"},{"Id":402851,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW TROPICAL","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"50428029452"},{"Id":402852,"FormularyType":"OHP","DrugName":"CVS SENNA PL TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428029464"},{"Id":402853,"FormularyType":"OHP","DrugName":"CVS ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"50428029491"},{"Id":402854,"FormularyType":"OHP","DrugName":"CVS ALLERGY SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"50428029583"},{"Id":402855,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL APPLE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428029627"},{"Id":402856,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 50/20ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428029730"},{"Id":402857,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"50428029733"},{"Id":402858,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428029742"},{"Id":402859,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428029779"},{"Id":402860,"FormularyType":"OHP","DrugName":"CVS IRON TAB 27MG","DosageForm":"TABS - Tablet","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"50428029828"},{"Id":402861,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"50428029877"},{"Id":402862,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"50428029936"},{"Id":402863,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428029968"},{"Id":402864,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428029992"},{"Id":402865,"FormularyType":"OHP","DrugName":"CVS B12 LIQ 1000/15","DosageForm":"LIQD - Liquid","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000945","GenericName":"CYANOCOBALAMIN LIQUID 1000 MCG/15ML","NDC":"50428030012"},{"Id":402866,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640333","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-3.125 MCG (125 UNIT)","NDC":"50428030067"},{"Id":402867,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428030275"},{"Id":402868,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"50428030278"},{"Id":402869,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50428030347"},{"Id":402870,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"50428030412"},{"Id":402871,"FormularyType":"OHP","DrugName":"8HR PAIN ER TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"50428030440"},{"Id":402872,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428030441"},{"Id":402873,"FormularyType":"OHP","DrugName":"CVS C-LAX TAB 5MG","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428030567"},{"Id":402874,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428030716"},{"Id":402875,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428030760"},{"Id":402876,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428030774"},{"Id":402877,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428030808"},{"Id":402878,"FormularyType":"OHP","DrugName":"CORTISONE LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"50428030842"},{"Id":402879,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428030876"},{"Id":402880,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"50428030894"},{"Id":402881,"FormularyType":"OHP","DrugName":"CVS IBUPROFE SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428030930"},{"Id":402882,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428031058"},{"Id":402883,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50428031078"},{"Id":402884,"FormularyType":"OHP","DrugName":"CVS ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"50428031182"},{"Id":402885,"FormularyType":"OHP","DrugName":"CVS D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"50428031328"},{"Id":402886,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"50428031342"},{"Id":402887,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50428031380"},{"Id":402888,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428031400"},{"Id":402889,"FormularyType":"OHP","DrugName":"CVS D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"50428031441"},{"Id":402890,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428031533"},{"Id":402891,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428031575"},{"Id":402892,"FormularyType":"OHP","DrugName":"ALLERGY RELI CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100520","GenericName":"DIPHENHYDRAMINE HCL CHEW TAB 25 MG","NDC":"50428031593"},{"Id":402893,"FormularyType":"OHP","DrugName":"SCALP RELIEF LIQ 3%","DosageForm":"LIQD - Liquid","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030000912","GenericName":"SALICYLIC ACID LIQUID 3%","NDC":"50428031652"},{"Id":402894,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50428031818"},{"Id":402895,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428031840"},{"Id":402896,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"50428031878"},{"Id":402897,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428032003"},{"Id":402898,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"50428032005"},{"Id":402899,"FormularyType":"OHP","DrugName":"CVS ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428032024"},{"Id":402900,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"50428032067"},{"Id":402901,"FormularyType":"OHP","DrugName":"GENUINE ASPR TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"50428032084"},{"Id":402902,"FormularyType":"OHP","DrugName":"CVS ALLERGY CHW 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"50428032112"},{"Id":402903,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"50428032177"},{"Id":402904,"FormularyType":"OHP","DrugName":"CVS D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"50428032343"},{"Id":402905,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428032374"},{"Id":402906,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428032392"},{"Id":402907,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428032405"},{"Id":402908,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"50428032417"},{"Id":402909,"FormularyType":"OHP","DrugName":"CVS ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428032504"},{"Id":402910,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"50428032617"},{"Id":402911,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428032627"},{"Id":402912,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"50428032982"},{"Id":402913,"FormularyType":"OHP","DrugName":"ALLERGY REL CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428033020"},{"Id":402914,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"50428033106"},{"Id":402915,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428033239"},{"Id":402916,"FormularyType":"OHP","DrugName":"SMOOTH ANTAC CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428033429"},{"Id":402917,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428033440"},{"Id":402918,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428033572"},{"Id":402919,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"50428033753"},{"Id":402920,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"50428033796"},{"Id":402921,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"50428033823"},{"Id":402922,"FormularyType":"OHP","DrugName":"ACNE TREATMN GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"50428033841"},{"Id":402923,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"50428033892"},{"Id":402924,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50428034138"},{"Id":402925,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"50428034166"},{"Id":402926,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50428034174"},{"Id":402927,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50428034206"},{"Id":402928,"FormularyType":"OHP","DrugName":"CORTISONE OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"50428034255"},{"Id":402929,"FormularyType":"OHP","DrugName":"ADHESIVE PAD 4\"X4\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"50428034263"},{"Id":402930,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW RASPBERR","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"50428034295"},{"Id":402931,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"50428034347"},{"Id":402932,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"50428034354"},{"Id":402933,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428034365"},{"Id":402934,"FormularyType":"OHP","DrugName":"MELATONIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000150","GenericName":"MELATONIN CAP 5 MG","NDC":"50428034400"},{"Id":402935,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"50428034496"},{"Id":402936,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428034503"},{"Id":402937,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"50428034527"},{"Id":402938,"FormularyType":"OHP","DrugName":"CVS ANTACID/ SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"50428034541"},{"Id":402939,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"50428034560"},{"Id":402940,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"50428034583"},{"Id":402941,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50428034618"},{"Id":402942,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428034635"},{"Id":402943,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428034775"},{"Id":402944,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428034789"},{"Id":402945,"FormularyType":"OHP","DrugName":"CAPSAICIN HP CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"50428034819"},{"Id":402946,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"50428034918"},{"Id":402947,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50428035025"},{"Id":402948,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428035112"},{"Id":402949,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW GRAPE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"50428035136"},{"Id":402950,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428035290"},{"Id":402951,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428035408"},{"Id":402952,"FormularyType":"OHP","DrugName":"CVS GAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"50428035450"},{"Id":402953,"FormularyType":"OHP","DrugName":"CVS SUPER B TAB COMPLX/C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"50428035460"},{"Id":402954,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428035555"},{"Id":402955,"FormularyType":"OHP","DrugName":"ADHESIVE PAD PAD 2.25\"X3\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"50428035632"},{"Id":402956,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428035787"},{"Id":402957,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428035813"},{"Id":402958,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"50428035827"},{"Id":402959,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428035859"},{"Id":402960,"FormularyType":"OHP","DrugName":"SMOOTH ANTAC CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428035866"},{"Id":402961,"FormularyType":"OHP","DrugName":"CVS IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"50428035980"},{"Id":402962,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428035992"},{"Id":402963,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428036049"},{"Id":402964,"FormularyType":"OHP","DrugName":"PRENATAL CHW GUMMIES","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000524","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.18-25 MG***","NDC":"50428036208"},{"Id":402965,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428036221"},{"Id":402966,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"50428036358"},{"Id":402967,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"50428036435"},{"Id":402968,"FormularyType":"OHP","DrugName":"CVS MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"50428036441"},{"Id":402969,"FormularyType":"OHP","DrugName":"CVS PURELAX PAK","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"50428036617"},{"Id":402970,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428036644"},{"Id":402971,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428036825"},{"Id":402972,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428037194"},{"Id":402973,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW TROPICAL","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"50428037205"},{"Id":402974,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"50428037438"},{"Id":402975,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"50428037489"},{"Id":402976,"FormularyType":"OHP","DrugName":"CVS SUPER B TAB COMPLX/C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"50428037587"},{"Id":402977,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"50428037624"},{"Id":402978,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428037702"},{"Id":402979,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428037778"},{"Id":402980,"FormularyType":"OHP","DrugName":"CVS SENNA PL TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428037837"},{"Id":402981,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428037875"},{"Id":402982,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"50428037924"},{"Id":402983,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428037987"},{"Id":402984,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"50428038014"},{"Id":402985,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428038036"},{"Id":402986,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428038143"},{"Id":402987,"FormularyType":"OHP","DrugName":"CVS MICONAZO CRE 7","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"50428038300"},{"Id":402988,"FormularyType":"OHP","DrugName":"CVS D3 CAP 10MCG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"50428038354"},{"Id":402989,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"50428038401"},{"Id":402990,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428038441"},{"Id":402991,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"50428038472"},{"Id":402992,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"50428038501"},{"Id":402993,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428038612"},{"Id":402994,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"50428038689"},{"Id":402995,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428038706"},{"Id":402996,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428038730"},{"Id":402997,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"50428038771"},{"Id":402998,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL PINEAPPL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428038805"},{"Id":402999,"FormularyType":"OHP","DrugName":"CVS RINGWORM CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"50428038808"},{"Id":403000,"FormularyType":"OHP","DrugName":"CORTISONE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"50428038812"},{"Id":403001,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"50428038823"},{"Id":403002,"FormularyType":"OHP","DrugName":"MOTION SICK CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"50428038936"},{"Id":403003,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428038943"},{"Id":403004,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428039053"},{"Id":403005,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"50428039209"},{"Id":403006,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428039434"},{"Id":403007,"FormularyType":"OHP","DrugName":"CVS ALLERGY DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50428039542"},{"Id":403008,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"50428039561"},{"Id":403009,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"50428039687"},{"Id":403010,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428039691"},{"Id":403011,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"50428039941"},{"Id":403012,"FormularyType":"OHP","DrugName":"PRENAT MULTI CAP +DHA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000130","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 27-0.8-250 MG***","NDC":"50428039950"},{"Id":403013,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428039970"},{"Id":403014,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428039978"},{"Id":403015,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"50428040067"},{"Id":403016,"FormularyType":"OHP","DrugName":"CVS D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"50428040225"},{"Id":403017,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"50428040311"},{"Id":403018,"FormularyType":"OHP","DrugName":"CVS ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"50428040502"},{"Id":403019,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"50428040525"},{"Id":403020,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428040647"},{"Id":403021,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50428041039"},{"Id":403022,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428041128"},{"Id":403023,"FormularyType":"OHP","DrugName":"DAILY FIBER CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"50428041152"},{"Id":403024,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"50428041276"},{"Id":403025,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428041286"},{"Id":403026,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428041312"},{"Id":403027,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428041354"},{"Id":403028,"FormularyType":"OHP","DrugName":"CVS D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"50428041389"},{"Id":403029,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428041536"},{"Id":403030,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428041604"},{"Id":403031,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428041795"},{"Id":403032,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428041924"},{"Id":403033,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428042000"},{"Id":403034,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"50428042025"},{"Id":403035,"FormularyType":"OHP","DrugName":"CVS LICE KIL SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"50428042075"},{"Id":403036,"FormularyType":"OHP","DrugName":"CVS QUALITY CAP SLEEP","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"50428042135"},{"Id":403037,"FormularyType":"OHP","DrugName":"CVS IBUPROF DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"50428042157"},{"Id":403038,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"50428042300"},{"Id":403039,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"50428042388"},{"Id":403040,"FormularyType":"OHP","DrugName":"PSYLLIUM POW 100%","DosageForm":"POWD - Powder","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102999","GenericName":"PSYLLIUM POWDER 100%","NDC":"50428042390"},{"Id":403041,"FormularyType":"OHP","DrugName":"MELATONIN TAB 12MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007265","GenericName":"MELATONIN TABLET DISINTEGRATING 12 MG","NDC":"50428042669"},{"Id":403042,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"50428042671"},{"Id":403043,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428042724"},{"Id":403044,"FormularyType":"OHP","DrugName":"CVS GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"50428042738"},{"Id":403045,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428042752"},{"Id":403046,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"50428042790"},{"Id":403047,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428042844"},{"Id":403048,"FormularyType":"OHP","DrugName":"CALC CITR+D3 TAB 400-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"50428042845"},{"Id":403049,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428042853"},{"Id":403050,"FormularyType":"OHP","DrugName":"CVS B6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"50428043019"},{"Id":403051,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"50428043083"},{"Id":403052,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428043095"},{"Id":403053,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428043161"},{"Id":403054,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428043198"},{"Id":403055,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428043242"},{"Id":403056,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428043243"},{"Id":403057,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50428043324"},{"Id":403058,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"50428043359"},{"Id":403059,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428043368"},{"Id":403060,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428043382"},{"Id":403061,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428043405"},{"Id":403062,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"50428043641"},{"Id":403063,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"50428043715"},{"Id":403064,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428043808"},{"Id":403065,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"50428043890"},{"Id":403066,"FormularyType":"OHP","DrugName":"CVS D3 CAP 10MCG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"50428043926"},{"Id":403067,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"50428043950"},{"Id":403068,"FormularyType":"OHP","DrugName":"FLAVOR CHEWS CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428043984"},{"Id":403069,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"50428044192"},{"Id":403070,"FormularyType":"OHP","DrugName":"CVS PRENATAL CAP MULTIVIT","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020000130","GenericName":"*PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 27-0.8-250 MG***","NDC":"50428044257"},{"Id":403071,"FormularyType":"OHP","DrugName":"CVS IBUPROF DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"50428044588"},{"Id":403072,"FormularyType":"OHP","DrugName":"CVS OMEPRAZO TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"50428044906"},{"Id":403073,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428045104"},{"Id":403074,"FormularyType":"OHP","DrugName":"FOAMING FACE LIQ WSH 10%","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"50428045366"},{"Id":403075,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"50428045563"},{"Id":403076,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL BERRY FR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428045606"},{"Id":403077,"FormularyType":"OHP","DrugName":"CVS GAUZE PD PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"50428045674"},{"Id":403078,"FormularyType":"OHP","DrugName":"ALRGY & HIVE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428045700"},{"Id":403079,"FormularyType":"OHP","DrugName":"SLOW RELEASE TAB 143MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"50428046055"},{"Id":403080,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"50428046298"},{"Id":403081,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428046729"},{"Id":403082,"FormularyType":"OHP","DrugName":"CVS SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"50428046812"},{"Id":403083,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428047092"},{"Id":403084,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"50428047181"},{"Id":403085,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428047235"},{"Id":403086,"FormularyType":"OHP","DrugName":"3-IN-1 CLEAN LIQ 5%","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"50428047280"},{"Id":403087,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428047304"},{"Id":403088,"FormularyType":"OHP","DrugName":"CVS ALLERGY DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50428047359"},{"Id":403089,"FormularyType":"OHP","DrugName":"PREP PADS PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50428047377"},{"Id":403090,"FormularyType":"OHP","DrugName":"CVS ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428047392"},{"Id":403091,"FormularyType":"OHP","DrugName":"CVS NATURAL POW FIBER","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"50428047458"},{"Id":403092,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428047491"},{"Id":403093,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428047559"},{"Id":403094,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428047702"},{"Id":403095,"FormularyType":"OHP","DrugName":"DAILY FIBER POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"50428047777"},{"Id":403096,"FormularyType":"OHP","DrugName":"SKIN TRTMENT LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"50428047796"},{"Id":403097,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50428047857"},{"Id":403098,"FormularyType":"OHP","DrugName":"CVS NATURAL POW FIBER","DosageForm":"POWD - Powder","Strength":"58.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102958","GenericName":"PSYLLIUM POWDER 58.6%","NDC":"50428047931"},{"Id":403099,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"50428047989"},{"Id":403100,"FormularyType":"OHP","DrugName":"ANTACID KIDS CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50428048125"},{"Id":403101,"FormularyType":"OHP","DrugName":"CVS VIT B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"50428048156"},{"Id":403102,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428048253"},{"Id":403103,"FormularyType":"OHP","DrugName":"CVS B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"50428048545"},{"Id":403104,"FormularyType":"OHP","DrugName":"PSORIASIS SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"50428048977"},{"Id":403105,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428049453"},{"Id":403106,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"50428049803"},{"Id":403107,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"50428051468"},{"Id":403108,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428051962"},{"Id":403109,"FormularyType":"OHP","DrugName":"CVS COVID-19 KIT HOME 2PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"50428052130"},{"Id":403110,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"50428052804"},{"Id":403111,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428052920"},{"Id":403112,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"50428053389"},{"Id":403113,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428053491"},{"Id":403114,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428053706"},{"Id":403115,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 5MG/15ML","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000930","GenericName":"MELATONIN LIQUID 5 MG/15ML","NDC":"50428053791"},{"Id":403116,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428053798"},{"Id":403117,"FormularyType":"OHP","DrugName":"CVS PRENATAL CHW GUMMY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000530","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.4-25 MG***","NDC":"50428054024"},{"Id":403118,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 50MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"50428054076"},{"Id":403119,"FormularyType":"OHP","DrugName":"CVS D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"50428054089"},{"Id":403120,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"50428054198"},{"Id":403121,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"50428054266"},{"Id":403122,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW CHOC MAR","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"50428054363"},{"Id":403123,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"50428054474"},{"Id":403124,"FormularyType":"OHP","DrugName":"ACETAMINOPHE CAP 325MG","DosageForm":"CAPS - Capsule","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000110","GenericName":"ACETAMINOPHEN CAP 325 MG","NDC":"50428054774"},{"Id":403125,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"50428054780"},{"Id":403126,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428055554"},{"Id":403127,"FormularyType":"OHP","DrugName":"CVS B-12 LIQ 1000/15","DosageForm":"LIQD - Liquid","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000945","GenericName":"CYANOCOBALAMIN LIQUID 1000 MCG/15ML","NDC":"50428055638"},{"Id":403128,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1/2 SIZE","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"50428055807"},{"Id":403129,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"50428055955"},{"Id":403130,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428056457"},{"Id":403131,"FormularyType":"OHP","DrugName":"CVS ANTIBIOT OIN 1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"50428056627"},{"Id":403132,"FormularyType":"OHP","DrugName":"CVS ANTIBIOT OIN 1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"50428057136"},{"Id":403133,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"50428057523"},{"Id":403134,"FormularyType":"OHP","DrugName":"CVS IBUPROFE SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428057864"},{"Id":403135,"FormularyType":"OHP","DrugName":"PAIN RELIEF CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"50428057988"},{"Id":403136,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"50428059017"},{"Id":403137,"FormularyType":"OHP","DrugName":"CVS OMEPRAZO TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"50428059507"},{"Id":403138,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"50428059700"},{"Id":403139,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300105","GenericName":"DOCUSATE SODIUM CAP 50 MG","NDC":"50428060633"},{"Id":403140,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"50428061092"},{"Id":403141,"FormularyType":"OHP","DrugName":"SKIN TRTMENT LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"50428061155"},{"Id":403142,"FormularyType":"OHP","DrugName":"CVS ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428061238"},{"Id":403143,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428061400"},{"Id":403144,"FormularyType":"OHP","DrugName":"CVS IBUPROFE SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"50428061412"},{"Id":403145,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50428062110"},{"Id":403146,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"50428062162"},{"Id":403147,"FormularyType":"OHP","DrugName":"CVS PURELAX PAK","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"50428062417"},{"Id":403148,"FormularyType":"OHP","DrugName":"CVS ANTACID/ SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"50428063305"},{"Id":403149,"FormularyType":"OHP","DrugName":"CVS OLOPATAD SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"50428063392"},{"Id":403150,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"50428063427"},{"Id":403151,"FormularyType":"OHP","DrugName":"CVS OLOPATAD SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"50428063531"},{"Id":403152,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"50428063687"},{"Id":403153,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"50428064244"},{"Id":403154,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"50428064275"},{"Id":403155,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"50428064681"},{"Id":403156,"FormularyType":"OHP","DrugName":"CVS D3 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"50428065144"},{"Id":403157,"FormularyType":"OHP","DrugName":"CVS D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"50428067309"},{"Id":403158,"FormularyType":"OHP","DrugName":"GLYCERIN PED SUP 1GM","DosageForm":"SUPP - Suppository","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005206","GenericName":"GLYCERIN SUPPOS 1 GM","NDC":"50428070109"},{"Id":403159,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"50428072785"},{"Id":403160,"FormularyType":"OHP","DrugName":"PREP PADS PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50428085942"},{"Id":403161,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428092378"},{"Id":403162,"FormularyType":"OHP","DrugName":"CVS GLUCOSE CHW GRAPE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"50428093407"},{"Id":403163,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428094796"},{"Id":403164,"FormularyType":"OHP","DrugName":"CVS FIBR LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"50428096918"},{"Id":403165,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428102194"},{"Id":403166,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428102202"},{"Id":403167,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428109017"},{"Id":403168,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428111047"},{"Id":403169,"FormularyType":"OHP","DrugName":"SLOW RELEASE TAB 143MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"50428122862"},{"Id":403170,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ STRABERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428142158"},{"Id":403171,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428142430"},{"Id":403172,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428142570"},{"Id":403173,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428142695"},{"Id":403174,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ STRABERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428142737"},{"Id":403175,"FormularyType":"OHP","DrugName":"CVS NUTRITIO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50428142828"},{"Id":403176,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"50428155756"},{"Id":403177,"FormularyType":"OHP","DrugName":"CVS FIBER CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"50428252794"},{"Id":403178,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428253566"},{"Id":403179,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428253568"},{"Id":403180,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428271255"},{"Id":403181,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FREEZPOP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428272877"},{"Id":403182,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428299483"},{"Id":403183,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"50428300263"},{"Id":403184,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"50428303693"},{"Id":403185,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"50428303719"},{"Id":403186,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"50428318599"},{"Id":403187,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"50428328147"},{"Id":403188,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428346565"},{"Id":403189,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50428348639"},{"Id":403190,"FormularyType":"OHP","DrugName":"CVS FIBER CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"50428348642"},{"Id":403191,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428348677"},{"Id":403192,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428348681"},{"Id":403193,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428367126"},{"Id":403194,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"50428367404"},{"Id":403195,"FormularyType":"OHP","DrugName":"B COMPLEX TAB PLUS C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"50428375469"},{"Id":403196,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428394372"},{"Id":403197,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428394375"},{"Id":403198,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428396725"},{"Id":403199,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428396726"},{"Id":403200,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"50428396728"},{"Id":403201,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"50428396729"},{"Id":403202,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"50428402521"},{"Id":403203,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"50428410600"},{"Id":403204,"FormularyType":"OHP","DrugName":"ALCOHOL WIPE MIS 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"50428444797"},{"Id":403205,"FormularyType":"OHP","DrugName":"SLOW RELEASE TAB 143MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"50428460967"},{"Id":403206,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"50428473604"},{"Id":403207,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"50428500363"},{"Id":403208,"FormularyType":"OHP","DrugName":"CVS CHILDS CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"50428521278"},{"Id":403209,"FormularyType":"OHP","DrugName":"ULTRA SLEEP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"50428531509"},{"Id":403210,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428534826"},{"Id":403211,"FormularyType":"OHP","DrugName":"CVS LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"50428613836"},{"Id":403212,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"50428637298"},{"Id":403213,"FormularyType":"OHP","DrugName":"CVS ENEMA ENE DISPOSAB","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"50428657064"},{"Id":403214,"FormularyType":"OHP","DrugName":"MINERAL OIL ENE","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010005110","GenericName":"MINERAL OIL ENEMA","NDC":"50428689618"},{"Id":403215,"FormularyType":"OHP","DrugName":"CVS FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"50428689754"},{"Id":403216,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"50428690036"},{"Id":403217,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"50428690044"},{"Id":403218,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"50428690111"},{"Id":403219,"FormularyType":"OHP","DrugName":"ANTACID MAX CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"50428690265"},{"Id":403220,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"50428694766"},{"Id":403221,"FormularyType":"OHP","DrugName":"CVS MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428695036"},{"Id":403222,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB REL/RR","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"50428695046"},{"Id":403223,"FormularyType":"OHP","DrugName":"SKIN TRTMENT LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"50428705146"},{"Id":403224,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"50428707721"},{"Id":403225,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428707932"},{"Id":403226,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"50428717943"},{"Id":403227,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50428738104"},{"Id":403228,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 5MG/15ML","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000930","GenericName":"MELATONIN LIQUID 5 MG/15ML","NDC":"50428802565"},{"Id":403229,"FormularyType":"OHP","DrugName":"CVS B-12 LIQ 1000/15","DosageForm":"LIQD - Liquid","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000945","GenericName":"CYANOCOBALAMIN LIQUID 1000 MCG/15ML","NDC":"50428802566"},{"Id":403230,"FormularyType":"OHP","DrugName":"SKIN TRTMENT LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"50428803406"},{"Id":403231,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 12MG CR","DosageForm":"TBCR - Tablet ER","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150410","GenericName":"CHLORPHENIRAMINE MALEATE TAB ER 12 MG","NDC":"50428832002"},{"Id":403232,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"50428833152"},{"Id":403233,"FormularyType":"OHP","DrugName":"CVS ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428839138"},{"Id":403234,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50428844542"},{"Id":403235,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428847260"},{"Id":403236,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428847261"},{"Id":403237,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428847263"},{"Id":403238,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428847264"},{"Id":403239,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428858866"},{"Id":403240,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428858867"},{"Id":403241,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"50428858868"},{"Id":403242,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"50428885431"},{"Id":403243,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428888489"},{"Id":403244,"FormularyType":"OHP","DrugName":"FOAMING FACE LIQ WSH 10%","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"50428892053"},{"Id":403245,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"50428901417"},{"Id":403246,"FormularyType":"OHP","DrugName":"CVS ELECTROL SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"50428912667"},{"Id":403247,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"50428912859"},{"Id":403248,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"50428912871"},{"Id":403249,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50428948312"},{"Id":403250,"FormularyType":"OHP","DrugName":"CVS ALLERGY DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50428955060"},{"Id":403251,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50428955063"},{"Id":403252,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"50428955064"},{"Id":403253,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428955066"},{"Id":403254,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"50428955067"},{"Id":403255,"FormularyType":"OHP","DrugName":"CVS ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50428955519"},{"Id":403256,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428955753"},{"Id":403257,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"50428955754"},{"Id":403258,"FormularyType":"OHP","DrugName":"CVS FIBER LA TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"50428969188"},{"Id":403259,"FormularyType":"OHP","DrugName":"ELMIRON CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"INTERSTITIAL CYSTITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56500060100110","GenericName":"PENTOSAN POLYSULFATE SODIUM CAPS 100 MG","NDC":"50458009801"},{"Id":403260,"FormularyType":"OHP","DrugName":"XARELTO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000330","GenericName":"RIVAROXABAN TAB 15 MG","NDC":"50458057801"},{"Id":403261,"FormularyType":"OHP","DrugName":"XARELTO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000330","GenericName":"RIVAROXABAN TAB 15 MG","NDC":"50458057810"},{"Id":403262,"FormularyType":"OHP","DrugName":"XARELTO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000330","GenericName":"RIVAROXABAN TAB 15 MG","NDC":"50458057830"},{"Id":403263,"FormularyType":"OHP","DrugName":"XARELTO TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000330","GenericName":"RIVAROXABAN TAB 15 MG","NDC":"50458057890"},{"Id":403264,"FormularyType":"OHP","DrugName":"XARELTO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000340","GenericName":"RIVAROXABAN TAB 20 MG","NDC":"50458057901"},{"Id":403265,"FormularyType":"OHP","DrugName":"XARELTO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000340","GenericName":"RIVAROXABAN TAB 20 MG","NDC":"50458057910"},{"Id":403266,"FormularyType":"OHP","DrugName":"XARELTO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000340","GenericName":"RIVAROXABAN TAB 20 MG","NDC":"50458057930"},{"Id":403267,"FormularyType":"OHP","DrugName":"XARELTO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000340","GenericName":"RIVAROXABAN TAB 20 MG","NDC":"50458057989"},{"Id":403268,"FormularyType":"OHP","DrugName":"XARELTO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000340","GenericName":"RIVAROXABAN TAB 20 MG","NDC":"50458057990"},{"Id":403269,"FormularyType":"OHP","DrugName":"XARELTO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000320","GenericName":"RIVAROXABAN TAB 10 MG","NDC":"50458058001"},{"Id":403270,"FormularyType":"OHP","DrugName":"XARELTO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000320","GenericName":"RIVAROXABAN TAB 10 MG","NDC":"50458058010"},{"Id":403271,"FormularyType":"OHP","DrugName":"XARELTO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000320","GenericName":"RIVAROXABAN TAB 10 MG","NDC":"50458058030"},{"Id":403272,"FormularyType":"OHP","DrugName":"XARELTO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83370060000320","GenericName":"RIVAROXABAN TAB 10 MG","NDC":"50458058090"},{"Id":403273,"FormularyType":"OHP","DrugName":"XARELTO STAR TAB 15/20MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"DIRECT FACTOR XA INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8337006000B720","GenericName":"RIVAROXABAN TAB STARTER THERAPY PACK 15 MG & 20 MG","NDC":"50458058451"},{"Id":403274,"FormularyType":"OHP","DrugName":"ZILBRYSQ INJ 16.6MG","DosageForm":"SOSY - Soln Pref Syr","Strength":"16.6","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8580509520E520","GenericName":"ZILUCOPLAN SODIUM SUBCUTANEOUS SOLN PREF SYR 16.6 MG/0.416ML","NDC":"50474099080"},{"Id":403275,"FormularyType":"OHP","DrugName":"ZILBRYSQ INJ 23MG","DosageForm":"SOSY - Soln Pref Syr","Strength":"23","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8580509520E530","GenericName":"ZILUCOPLAN SODIUM SUBCUTANEOUS SOLN PREF SYR 23 MG/0.574ML","NDC":"50474099180"},{"Id":403276,"FormularyType":"OHP","DrugName":"ZILBRYSQ INJ 32.4MG","DosageForm":"SOSY - Soln Pref Syr","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8580509520E540","GenericName":"ZILUCOPLAN SODIUM SUBCUTANEOUS SOLN PREF SYR 32.4 MG/0.81ML","NDC":"50474099280"},{"Id":403277,"FormularyType":"OHP","DrugName":"POCKETPEAK MIS MTR LOW","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"50486008321"},{"Id":403278,"FormularyType":"OHP","DrugName":"ASSESS METER MIS FULL","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"50486008410"},{"Id":403279,"FormularyType":"OHP","DrugName":"PERSONAL BES MIS FULL RNG","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"50486008413"},{"Id":403280,"FormularyType":"OHP","DrugName":"ASSESS METER MIS LOW","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"50486008415"},{"Id":403281,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"50488102501"},{"Id":403282,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"50488102502"},{"Id":403283,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"50488102505"},{"Id":403284,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.035%","DosageForm":"CREA - Cream","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003715","GenericName":"CAPSAICIN CREAM 0.035%","NDC":"50488103501"},{"Id":403285,"FormularyType":"OHP","DrugName":"CAPSAICIN HP CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"50488106006"},{"Id":403286,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.075%","DosageForm":"CREA - Cream","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003730","GenericName":"CAPSAICIN CREAM 0.075%","NDC":"50488107501"},{"Id":403287,"FormularyType":"OHP","DrugName":"DXTERITY TES KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024306400","GenericName":"COVID-19 HOME COLLECTION TEST KIT","NDC":"50521000612"},{"Id":403288,"FormularyType":"OHP","DrugName":"TYLENOL CAP 325MG","DosageForm":"CAPS - Capsule","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000110","GenericName":"ACETAMINOPHEN CAP 325 MG","NDC":"50580048720"},{"Id":403289,"FormularyType":"OHP","DrugName":"TYLENOL CAP 325MG","DosageForm":"CAPS - Capsule","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000110","GenericName":"ACETAMINOPHEN CAP 325 MG","NDC":"50580048790"},{"Id":403290,"FormularyType":"OHP","DrugName":"TYLENOL CHIL CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"50580052124"},{"Id":403291,"FormularyType":"OHP","DrugName":"TYLENOL CHIL CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"50580052224"},{"Id":403292,"FormularyType":"OHP","DrugName":"LIPISTART POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600050205"},{"Id":403293,"FormularyType":"OHP","DrugName":"MSUD COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600050915"},{"Id":403294,"FormularyType":"OHP","DrugName":"PKU COOLR 10 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600051318"},{"Id":403295,"FormularyType":"OHP","DrugName":"PKU TRIO POW UNFLAVOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600051806"},{"Id":403296,"FormularyType":"OHP","DrugName":"PKU TRIO POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600051813"},{"Id":403297,"FormularyType":"OHP","DrugName":"UCD TRIO POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600051820"},{"Id":403298,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600051998"},{"Id":403299,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600052001"},{"Id":403300,"FormularyType":"OHP","DrugName":"PKU TRIO POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600053138"},{"Id":403301,"FormularyType":"OHP","DrugName":"PKU TRIO POW UNFLAVOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600053145"},{"Id":403302,"FormularyType":"OHP","DrugName":"HCU COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600053527"},{"Id":403303,"FormularyType":"OHP","DrugName":"TYR COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600053992"},{"Id":403304,"FormularyType":"OHP","DrugName":"TYR COOLER LIQ RED","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600054326"},{"Id":403305,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600054500"},{"Id":403306,"FormularyType":"OHP","DrugName":"PKU COOLR 15 LIQ PURPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600054562"},{"Id":403307,"FormularyType":"OHP","DrugName":"MSUD COOLER LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600054654"},{"Id":403308,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600054814"},{"Id":403309,"FormularyType":"OHP","DrugName":"PKU COOLR 20 LIQ PURPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600054838"},{"Id":403310,"FormularyType":"OHP","DrugName":"UCD TRIO POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"50600056054"},{"Id":403311,"FormularyType":"OHP","DrugName":"MMA/PA LIQ COOLER15","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"50600056122"},{"Id":403312,"FormularyType":"OHP","DrugName":"JYNNEOS INJ","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100084101820","GenericName":"SMALLPOX & MONKEYPOX VAC, LIVE, NON-REPLICATING INJ 0.5 ML","NDC":"50632000101"},{"Id":403313,"FormularyType":"OHP","DrugName":"JYNNEOS INJ","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100084101820","GenericName":"SMALLPOX & MONKEYPOX VAC, LIVE, NON-REPLICATING INJ 0.5 ML","NDC":"50632000102"},{"Id":403314,"FormularyType":"OHP","DrugName":"JYNNEOS INJ","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100084101820","GenericName":"SMALLPOX & MONKEYPOX VAC, LIVE, NON-REPLICATING INJ 0.5 ML","NDC":"50632000103"},{"Id":403315,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50632000700"},{"Id":403316,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"50632000702"},{"Id":403317,"FormularyType":"OHP","DrugName":"PRO COMFORT PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50632000703"},{"Id":403318,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"50632000704"},{"Id":403319,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"50632000705"},{"Id":403320,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"50632000706"},{"Id":403321,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"50632000707"},{"Id":403322,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"50632000708"},{"Id":403323,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"50632000709"},{"Id":403324,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"50632000710"},{"Id":403325,"FormularyType":"OHP","DrugName":"PRO COMFORT MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"50632000711"},{"Id":403326,"FormularyType":"OHP","DrugName":"SAPS HEALTH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50632000715"},{"Id":403327,"FormularyType":"OHP","DrugName":"SPACER CHAMB MIS ADULT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50632000727"},{"Id":403328,"FormularyType":"OHP","DrugName":"SPACER CHAMB MIS CHILD","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50632000728"},{"Id":403329,"FormularyType":"OHP","DrugName":"SAPS HEALTH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50632000733"},{"Id":403330,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/32G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906343","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X 5/16\"","NDC":"50632000740"},{"Id":403331,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/32G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906344","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16\"","NDC":"50632000741"},{"Id":403332,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"50632000744"},{"Id":403333,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"50632000745"},{"Id":403334,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"50632000746"},{"Id":403335,"FormularyType":"OHP","DrugName":"SPACER CHAMB MIS INFANT","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"50632000756"},{"Id":403336,"FormularyType":"OHP","DrugName":"INS SYR 1ML MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"50632000772"},{"Id":403337,"FormularyType":"OHP","DrugName":"INS SY 0.5ML MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"50632000773"},{"Id":403338,"FormularyType":"OHP","DrugName":"INS SYR 1ML MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"50632000774"},{"Id":403339,"FormularyType":"OHP","DrugName":"ZEVRX STERIL PAD ALCHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50632000775"},{"Id":403340,"FormularyType":"OHP","DrugName":"ZEVRX MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50632000777"},{"Id":403341,"FormularyType":"OHP","DrugName":"ZEVRX MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50632000778"},{"Id":403342,"FormularyType":"OHP","DrugName":"ZEVRX MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"50632000779"},{"Id":403343,"FormularyType":"OHP","DrugName":"ZEVRX MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50632000780"},{"Id":403344,"FormularyType":"OHP","DrugName":"INS SY 0.5ML MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"50632000782"},{"Id":403345,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50632000787"},{"Id":403346,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"50632000789"},{"Id":403347,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"50632000790"},{"Id":403348,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"50632000791"},{"Id":403349,"FormularyType":"OHP","DrugName":"RABAVERT INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100070201900","GenericName":"RABIES VACCINE, PCEC FOR INJ","NDC":"50632001001"},{"Id":403350,"FormularyType":"OHP","DrugName":"RABAVERT INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100070201900","GenericName":"RABIES VACCINE, PCEC FOR INJ","NDC":"50632001301"},{"Id":403351,"FormularyType":"OHP","DrugName":"VAXCHORA SUS","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200020101910","GenericName":"*CHOLERA VACCINE LIVE ATTENUATED FOR ORAL SUSP**","NDC":"50632001502"},{"Id":403352,"FormularyType":"OHP","DrugName":"VIVOTIF CAP EC","DosageForm":"CPDR - Capsule Delayed Release","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200080006500","GenericName":"TYPHOID VACCINE CAP DELAYED RELEASE","NDC":"50632001602"},{"Id":403353,"FormularyType":"OHP","DrugName":"VIVOTIF CAP EC","DosageForm":"CPDR - Capsule Delayed Release","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17200080006500","GenericName":"TYPHOID VACCINE CAP DELAYED RELEASE","NDC":"50632001604"},{"Id":403354,"FormularyType":"OHP","DrugName":"VIMKUNYA INJ 40/0.8ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000120E630","GenericName":"CHIKUNGUNYA VIRUS VAC RCMB VLP IM SUSP PREF SYR 40 MCG/0.8ML","NDC":"50632001802"},{"Id":403355,"FormularyType":"OHP","DrugName":"VIMKUNYA INJ 40/0.8ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000120E630","GenericName":"CHIKUNGUNYA VIRUS VAC RCMB VLP IM SUSP PREF SYR 40 MCG/0.8ML","NDC":"50632001804"},{"Id":403356,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"50742011808"},{"Id":403357,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"50742017501"},{"Id":403358,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"50742017505"},{"Id":403359,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"50742017601"},{"Id":403360,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"50742017605"},{"Id":403361,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 120MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007540","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG","NDC":"50742017701"},{"Id":403362,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"50742018101"},{"Id":403363,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"50742018130"},{"Id":403364,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"50742018212"},{"Id":403365,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"50742018224"},{"Id":403366,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100335","GenericName":"LEUCOVORIN CALCIUM TAB 15 MG","NDC":"50742018324"},{"Id":403367,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100345","GenericName":"LEUCOVORIN CALCIUM TAB 25 MG","NDC":"50742018425"},{"Id":403368,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"50742019001"},{"Id":403369,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"50742023301"},{"Id":403370,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"50742023901"},{"Id":403371,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"50742024001"},{"Id":403372,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"50742024101"},{"Id":403373,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"50742024830"},{"Id":403374,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"50742024890"},{"Id":403375,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"50742024930"},{"Id":403376,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"50742024990"},{"Id":403377,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"50742025030"},{"Id":403378,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"50742025090"},{"Id":403379,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"50742025130"},{"Id":403380,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"50742025190"},{"Id":403381,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"50742025230"},{"Id":403382,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"50742025290"},{"Id":403383,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"50742025701"},{"Id":403384,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"50742025801"},{"Id":403385,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"50742025901"},{"Id":403386,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"50742026001"},{"Id":403387,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"50742026003"},{"Id":403388,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"50742026101"},{"Id":403389,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"50742026103"},{"Id":403390,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"50742026201"},{"Id":403391,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"50742026203"},{"Id":403392,"FormularyType":"OHP","DrugName":"PROBEN/COLCH TAB 500-0.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENT COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68990002100310","GenericName":"COLCHICINE W/ PROBENECID TAB 0.5-500 MG","NDC":"50742026301"},{"Id":403393,"FormularyType":"OHP","DrugName":"NORETHIN ACE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000030100305","GenericName":"NORETHINDRONE ACETATE TAB 5 MG","NDC":"50742026750"},{"Id":403394,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007207530","GenericName":"DICLOFENAC SODIUM TAB ER 24HR 100 MG","NDC":"50742027801"},{"Id":403395,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"50742027901"},{"Id":403396,"FormularyType":"OHP","DrugName":"COLESTIPOL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020100320","GenericName":"COLESTIPOL HCL TAB 1 GM","NDC":"50742028412"},{"Id":403397,"FormularyType":"OHP","DrugName":"FLUNISOLIDE SPR 0.025%","DosageForm":"SOLN - Solution","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200030002005","GenericName":"FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%)","NDC":"50742031725"},{"Id":403398,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"50742034901"},{"Id":403399,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"50742035001"},{"Id":403400,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"50742035101"},{"Id":403401,"FormularyType":"OHP","DrugName":"HER STYLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"50742035201"},{"Id":403402,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100320","GenericName":"IVABRADINE HCL TAB 5 MG (BASE EQUIV)","NDC":"50742036260"},{"Id":403403,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100330","GenericName":"IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","NDC":"50742036360"},{"Id":403404,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"50742036401"},{"Id":403405,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 8-2MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208240","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","NDC":"50742036430"},{"Id":403406,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"50742036501"},{"Id":403407,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 12-3MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208250","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","NDC":"50742036530"},{"Id":403408,"FormularyType":"OHP","DrugName":"GEFITINIB TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360030000320","GenericName":"GEFITINIB TAB 250 MG","NDC":"50742036630"},{"Id":403409,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"50742037201"},{"Id":403410,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"50742037204"},{"Id":403411,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 7.5/HR","DosageForm":"PTWK - Patch Weekly","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008825","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 7.5 MCG/HR","NDC":"50742037301"},{"Id":403412,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 7.5/HR","DosageForm":"PTWK - Patch Weekly","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008825","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 7.5 MCG/HR","NDC":"50742037304"},{"Id":403413,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"50742037401"},{"Id":403414,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"50742037404"},{"Id":403415,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"50742037501"},{"Id":403416,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"50742037504"},{"Id":403417,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"50742037601"},{"Id":403418,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"50742037604"},{"Id":403419,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"50742038642"},{"Id":403420,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"50742039205"},{"Id":403421,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"50742039225"},{"Id":403422,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"50742039305"},{"Id":403423,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"50742039325"},{"Id":403424,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"50742039701"},{"Id":403425,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 2-0.5MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208220","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","NDC":"50742039730"},{"Id":403426,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"50742039801"},{"Id":403427,"FormularyType":"OHP","DrugName":"BUPREN/NALOX MIS 4-1MG","DosageForm":"FILM - Film","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010208230","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","NDC":"50742039830"},{"Id":403428,"FormularyType":"OHP","DrugName":"NITRO-DUR DIS 0.3MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008530","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.3 MG/HR","NDC":"50742051501"},{"Id":403429,"FormularyType":"OHP","DrugName":"NITRO-DUR DIS 0.3MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008530","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.3 MG/HR","NDC":"50742051530"},{"Id":403430,"FormularyType":"OHP","DrugName":"NITRO-DUR DIS 0.8MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.8","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008560","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.8 MG/HR","NDC":"50742051801"},{"Id":403431,"FormularyType":"OHP","DrugName":"NITRO-DUR DIS 0.8MG/HR","DosageForm":"PT24 - Patch 24 HR","Strength":"0.8","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030008560","GenericName":"NITROGLYCERIN TD PATCH 24HR 0.8 MG/HR","NDC":"50742051830"},{"Id":403432,"FormularyType":"OHP","DrugName":"FENTANYL DIS 12MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008610","GenericName":"FENTANYL TD PATCH 72HR 12 MCG/HR","NDC":"50742054901"},{"Id":403433,"FormularyType":"OHP","DrugName":"FENTANYL DIS 12MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008610","GenericName":"FENTANYL TD PATCH 72HR 12 MCG/HR","NDC":"50742054905"},{"Id":403434,"FormularyType":"OHP","DrugName":"FENTANYL DIS 25MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008620","GenericName":"FENTANYL TD PATCH 72HR 25 MCG/HR","NDC":"50742055001"},{"Id":403435,"FormularyType":"OHP","DrugName":"FENTANYL DIS 25MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008620","GenericName":"FENTANYL TD PATCH 72HR 25 MCG/HR","NDC":"50742055005"},{"Id":403436,"FormularyType":"OHP","DrugName":"FENTANYL DIS 37.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008626","GenericName":"FENTANYL TD PATCH 72HR 37.5 MCG/HR","NDC":"50742055101"},{"Id":403437,"FormularyType":"OHP","DrugName":"FENTANYL DIS 37.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008626","GenericName":"FENTANYL TD PATCH 72HR 37.5 MCG/HR","NDC":"50742055105"},{"Id":403438,"FormularyType":"OHP","DrugName":"FENTANYL DIS 50MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008630","GenericName":"FENTANYL TD PATCH 72HR 50 MCG/HR","NDC":"50742055201"},{"Id":403439,"FormularyType":"OHP","DrugName":"FENTANYL DIS 50MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008630","GenericName":"FENTANYL TD PATCH 72HR 50 MCG/HR","NDC":"50742055205"},{"Id":403440,"FormularyType":"OHP","DrugName":"FENTANYL DIS 62.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"62.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008635","GenericName":"FENTANYL TD PATCH 72HR 62.5 MCG/HR","NDC":"50742055301"},{"Id":403441,"FormularyType":"OHP","DrugName":"FENTANYL DIS 62.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"62.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008635","GenericName":"FENTANYL TD PATCH 72HR 62.5 MCG/HR","NDC":"50742055305"},{"Id":403442,"FormularyType":"OHP","DrugName":"FENTANYL DIS 75MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008640","GenericName":"FENTANYL TD PATCH 72HR 75 MCG/HR","NDC":"50742055401"},{"Id":403443,"FormularyType":"OHP","DrugName":"FENTANYL DIS 75MCG/HR","DosageForm":"PT72 - Patch 72 HR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008640","GenericName":"FENTANYL TD PATCH 72HR 75 MCG/HR","NDC":"50742055405"},{"Id":403444,"FormularyType":"OHP","DrugName":"FENTANYL DIS 87.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"87.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008645","GenericName":"FENTANYL TD PATCH 72HR 87.5 MCG/HR","NDC":"50742055501"},{"Id":403445,"FormularyType":"OHP","DrugName":"FENTANYL DIS 87.5MCG","DosageForm":"PT72 - Patch 72 HR","Strength":"87.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008645","GenericName":"FENTANYL TD PATCH 72HR 87.5 MCG/HR","NDC":"50742055505"},{"Id":403446,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"50742055601"},{"Id":403447,"FormularyType":"OHP","DrugName":"FENTANYL DIS 100MCG/H","DosageForm":"PT72 - Patch 72 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100025008650","GenericName":"FENTANYL TD PATCH 72HR 100 MCG/HR","NDC":"50742055605"},{"Id":403448,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"50742056401"},{"Id":403449,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"50742056501"},{"Id":403450,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"50742056601"},{"Id":403451,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"50742061501"},{"Id":403452,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"50742061505"},{"Id":403453,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"50742061510"},{"Id":403454,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"50742061601"},{"Id":403455,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"50742061605"},{"Id":403456,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"50742061610"},{"Id":403457,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"50742061701"},{"Id":403458,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"50742061705"},{"Id":403459,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"50742061710"},{"Id":403460,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"50742061801"},{"Id":403461,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"50742061805"},{"Id":403462,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"50742061810"},{"Id":403463,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007530","GenericName":"NIFEDIPINE TAB ER 24HR 30 MG","NDC":"50742062001"},{"Id":403464,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007540","GenericName":"NIFEDIPINE TAB ER 24HR 60 MG","NDC":"50742062101"},{"Id":403465,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007550","GenericName":"NIFEDIPINE TAB ER 24HR 90 MG","NDC":"50742062201"},{"Id":403466,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"50742062360"},{"Id":403467,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000305","GenericName":"TRIAZOLAM TAB 0.125 MG","NDC":"50742064501"},{"Id":403468,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000310","GenericName":"TRIAZOLAM TAB 0.25 MG","NDC":"50742064601"},{"Id":403469,"FormularyType":"OHP","DrugName":"ESTRA/NORETH TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"50742065728"},{"Id":403470,"FormularyType":"OHP","DrugName":"ESTRA/NORETH TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"50742065784"},{"Id":403471,"FormularyType":"OHP","DrugName":"ESTRA/NORETH TAB 0.5-0.1","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120305","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","NDC":"50742065828"},{"Id":403472,"FormularyType":"OHP","DrugName":"ESTRA/NORETH TAB 0.5-0.1","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120305","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","NDC":"50742065884"},{"Id":403473,"FormularyType":"OHP","DrugName":"DOLISHALE TAB 90-20MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25994002350320","GenericName":"LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","NDC":"50742065928"},{"Id":403474,"FormularyType":"OHP","DrugName":"DOLISHALE TAB 90-20MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25994002350320","GenericName":"LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","NDC":"50742065984"},{"Id":403475,"FormularyType":"OHP","DrugName":"READY TO USE ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"50804000302"},{"Id":403476,"FormularyType":"OHP","DrugName":"READY TO USE ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"50804000401"},{"Id":403477,"FormularyType":"OHP","DrugName":"READY TO USE ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"50804000402"},{"Id":403478,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"50804000701"},{"Id":403479,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50804004893"},{"Id":403480,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"50804009108"},{"Id":403481,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"50804011217"},{"Id":403482,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"50804011317"},{"Id":403483,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50804012722"},{"Id":403484,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50804012822"},{"Id":403485,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"50804012922"},{"Id":403486,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"50804014352"},{"Id":403487,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"50804014794"},{"Id":403488,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"50804015712"},{"Id":403489,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"50804016438"},{"Id":403490,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"50804016638"},{"Id":403491,"FormularyType":"OHP","DrugName":"ANTACID ULTR CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"50804017168"},{"Id":403492,"FormularyType":"OHP","DrugName":"ANTACID ULTR CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"50804017568"},{"Id":403493,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"50804019802"},{"Id":403494,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"50804019940"},{"Id":403495,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"50804025304"},{"Id":403496,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"50804027793"},{"Id":403497,"FormularyType":"OHP","DrugName":"LAXATIVE PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50804030410"},{"Id":403498,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"50804032756"},{"Id":403499,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"50804037201"},{"Id":403500,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"50804041038"},{"Id":403501,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"50804042425"},{"Id":403502,"FormularyType":"OHP","DrugName":"LAXATIVE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"50804049224"},{"Id":403503,"FormularyType":"OHP","DrugName":"EYE ITCH REF DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"50804060105"},{"Id":403504,"FormularyType":"OHP","DrugName":"ANTACID & SUS GAS RELF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"50804062912"},{"Id":403505,"FormularyType":"OHP","DrugName":"GOODSENSE SUS ANTACID","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"50804063912"},{"Id":403506,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"50804064712"},{"Id":403507,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS CHERRY","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"50804064812"},{"Id":403508,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"50804064912"},{"Id":403509,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"50804082603"},{"Id":403510,"FormularyType":"OHP","DrugName":"GOODSENSE OIL MINERAL","DosageForm":"OIL - Oil","Strength":"99.9","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"50804083143"},{"Id":403511,"FormularyType":"OHP","DrugName":"LAXATIVE PLS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"50804085510"},{"Id":403512,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"50804086032"},{"Id":403513,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"50804086225"},{"Id":403514,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50804088001"},{"Id":403515,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"50804088004"},{"Id":403516,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"50804088210"},{"Id":403517,"FormularyType":"OHP","DrugName":"MENSTRUAL TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"50804099008"},{"Id":403518,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"50816002502"},{"Id":403519,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"50816002503"},{"Id":403520,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"50816005002"},{"Id":403521,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"50816005003"},{"Id":403522,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"50816010002"},{"Id":403523,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"50816010003"},{"Id":403524,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"50816020002"},{"Id":403525,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"50816020003"},{"Id":403526,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"50844032907"},{"Id":403527,"FormularyType":"OHP","DrugName":"JAKAFI TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537560200310","GenericName":"RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT)","NDC":"50881000560"},{"Id":403528,"FormularyType":"OHP","DrugName":"JAKAFI TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537560200320","GenericName":"RUXOLITINIB PHOSPHATE TAB 10 MG (BASE EQUIVALENT)","NDC":"50881001060"},{"Id":403529,"FormularyType":"OHP","DrugName":"JAKAFI TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537560200325","GenericName":"RUXOLITINIB PHOSPHATE TAB 15 MG (BASE EQUIVALENT)","NDC":"50881001560"},{"Id":403530,"FormularyType":"OHP","DrugName":"JAKAFI TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537560200330","GenericName":"RUXOLITINIB PHOSPHATE TAB 20 MG (BASE EQUIVALENT)","NDC":"50881002060"},{"Id":403531,"FormularyType":"OHP","DrugName":"JAKAFI TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537560200335","GenericName":"RUXOLITINIB PHOSPHATE TAB 25 MG (BASE EQUIVALENT)","NDC":"50881002560"},{"Id":403532,"FormularyType":"OHP","DrugName":"PEMAZYRE TAB 4.5MG","DosageForm":"TABS - Tablet","Strength":"4.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532260000320","GenericName":"PEMIGATINIB TAB 4.5 MG","NDC":"50881002601"},{"Id":403533,"FormularyType":"OHP","DrugName":"PEMAZYRE TAB 9MG","DosageForm":"TABS - Tablet","Strength":"9","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532260000330","GenericName":"PEMIGATINIB TAB 9 MG","NDC":"50881002701"},{"Id":403534,"FormularyType":"OHP","DrugName":"PEMAZYRE TAB 13.5MG","DosageForm":"TABS - Tablet","Strength":"13.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532260000340","GenericName":"PEMIGATINIB TAB 13.5 MG","NDC":"50881002801"},{"Id":403535,"FormularyType":"OHP","DrugName":"ALA-HIST IR TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100025100310","GenericName":"DEXBROMPHENIRAMINE MALEATE TAB 2 MG","NDC":"50991078360"},{"Id":403536,"FormularyType":"OHP","DrugName":"EVERLYWELL KIT HOME","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024306400","GenericName":"COVID-19 HOME COLLECTION TEST KIT","NDC":"51044000842"},{"Id":403537,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"51079002301"},{"Id":403538,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"51079002320"},{"Id":403539,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"51079002401"},{"Id":403540,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"51079002420"},{"Id":403541,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"51079002801"},{"Id":403542,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"51079002820"},{"Id":403543,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"51079005101"},{"Id":403544,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"51079005120"},{"Id":403545,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"51079005801"},{"Id":403546,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"51079005820"},{"Id":403547,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"51079007401"},{"Id":403548,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"51079007420"},{"Id":403549,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"51079007501"},{"Id":403550,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"51079007520"},{"Id":403551,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"51079007601"},{"Id":403552,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"51079007620"},{"Id":403553,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"51079008301"},{"Id":403554,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"51079008320"},{"Id":403555,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"51079009301"},{"Id":403556,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"51079009303"},{"Id":403557,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"51079010301"},{"Id":403558,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"51079010320"},{"Id":403559,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"51079012101"},{"Id":403560,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"51079012108"},{"Id":403561,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"51079020401"},{"Id":403562,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"51079020406"},{"Id":403563,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"51079020501"},{"Id":403564,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"51079020520"},{"Id":403565,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"51079020601"},{"Id":403566,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"51079020620"},{"Id":403567,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"51079020801"},{"Id":403568,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"51079020820"},{"Id":403569,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"51079020901"},{"Id":403570,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"51079020920"},{"Id":403571,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"51079021001"},{"Id":403572,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"51079021020"},{"Id":403573,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"51079021103"},{"Id":403574,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"51079025501"},{"Id":403575,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"51079025520"},{"Id":403576,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"51079030063"},{"Id":403577,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"51079030601"},{"Id":403578,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"51079030630"},{"Id":403579,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"51079044001"},{"Id":403580,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"51079044020"},{"Id":403581,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"51079044101"},{"Id":403582,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"51079044120"},{"Id":403583,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"51079044201"},{"Id":403584,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"51079044220"},{"Id":403585,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"51079044301"},{"Id":403586,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"51079044320"},{"Id":403587,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"51079044401"},{"Id":403588,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"51079044420"},{"Id":403589,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"51079044501"},{"Id":403590,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"51079044520"},{"Id":403591,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"51079045301"},{"Id":403592,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"51079045320"},{"Id":403593,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"51079045801"},{"Id":403594,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"51079045820"},{"Id":403595,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51079059701"},{"Id":403596,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51079059720"},{"Id":403597,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"51079059920"},{"Id":403598,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"51079060820"},{"Id":403599,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"51079068401"},{"Id":403600,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"51079068420"},{"Id":403601,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"51079068501"},{"Id":403602,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"51079068520"},{"Id":403603,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"51079075301"},{"Id":403604,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"51079075320"},{"Id":403605,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"51079075601"},{"Id":403606,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"51079075620"},{"Id":403607,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"51079075901"},{"Id":403608,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"51079075920"},{"Id":403609,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"51079078201"},{"Id":403610,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"51079078220"},{"Id":403611,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"51079079301"},{"Id":403612,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"51079079320"},{"Id":403613,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"51079079401"},{"Id":403614,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"51079079420"},{"Id":403615,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"51079079501"},{"Id":403616,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"51079079520"},{"Id":403617,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"51079080101"},{"Id":403618,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"51079080120"},{"Id":403619,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"51079081701"},{"Id":403620,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"51079081720"},{"Id":403621,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"51079081801"},{"Id":403622,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"51079081820"},{"Id":403623,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"51079082101"},{"Id":403624,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"51079082120"},{"Id":403625,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"51079088601"},{"Id":403626,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"51079088620"},{"Id":403627,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"51079088801"},{"Id":403628,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"51079088820"},{"Id":403629,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107020","GenericName":"VERAPAMIL HCL CAP ER 24HR 120 MG","NDC":"51079091701"},{"Id":403630,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107020","GenericName":"VERAPAMIL HCL CAP ER 24HR 120 MG","NDC":"51079091720"},{"Id":403631,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"51079092401"},{"Id":403632,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"51079092420"},{"Id":403633,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"51079092501"},{"Id":403634,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"51079092520"},{"Id":403635,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"51079092601"},{"Id":403636,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"51079092620"},{"Id":403637,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"51079097901"},{"Id":403638,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"51079097920"},{"Id":403639,"FormularyType":"OHP","DrugName":"WATERPROOF PAD 3\"X4\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"51131019773"},{"Id":403640,"FormularyType":"OHP","DrugName":"TUKYSA TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANTI-HER2 AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21170080000320","GenericName":"TUCATINIB TAB 50 MG","NDC":"51144000160"},{"Id":403641,"FormularyType":"OHP","DrugName":"TUKYSA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANTI-HER2 AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21170080000340","GenericName":"TUCATINIB TAB 150 MG","NDC":"51144000212"},{"Id":403642,"FormularyType":"OHP","DrugName":"TUKYSA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANTI-HER2 AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21170080000340","GenericName":"TUCATINIB TAB 150 MG","NDC":"51144000260"},{"Id":403643,"FormularyType":"OHP","DrugName":"TRIKAFTA TAB","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4530990340B720","GenericName":"ELEXACAF-TEZACAF-IVACAF 50-25-37.5 MG & IVACAFTOR 75 MG TBPK","NDC":"51167010602"},{"Id":403644,"FormularyType":"OHP","DrugName":"SYMDEKO TAB 50-75MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4530990280B710","GenericName":"TEZACAFTOR-IVACAFTOR 50-75 MG & IVACAFTOR 75 MG TAB TBPK","NDC":"51167011301"},{"Id":403645,"FormularyType":"OHP","DrugName":"ALYFTREK TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309903850325","GenericName":"VANZACAFTOR-TEZACAFTOR-DEUTIVACAFTOR TAB 10-50-125 MG","NDC":"51167012101"},{"Id":403646,"FormularyType":"OHP","DrugName":"ORKAMBI GRA 75-94MG","DosageForm":"PACK - Packet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309902303005","GenericName":"LUMACAFTOR-IVACAFTOR GRANULES PACKET 75-94 MG","NDC":"51167012201"},{"Id":403647,"FormularyType":"OHP","DrugName":"ALYFTREK TAB 4-20-50","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309903850310","GenericName":"VANZACAFTOR-TEZACAFTOR-DEUTIVACAFTOR TAB 4-20-50 MG","NDC":"51167013501"},{"Id":403648,"FormularyType":"OHP","DrugName":"KALYDECO TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45302030000320","GenericName":"IVACAFTOR TAB 150 MG","NDC":"51167020001"},{"Id":403649,"FormularyType":"OHP","DrugName":"KALYDECO PAK 50MG","DosageForm":"PACK - Packet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45302030003020","GenericName":"IVACAFTOR PACKET 50 MG","NDC":"51167030001"},{"Id":403650,"FormularyType":"OHP","DrugName":"TRIKAFTA TAB","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4530990340B740","GenericName":"ELEXACAF-TEZACAF-IVACAF 100-50-75 MG &IVACAFTOR 150 MG TBPK","NDC":"51167033101"},{"Id":403651,"FormularyType":"OHP","DrugName":"KALYDECO PAK 75MG","DosageForm":"PACK - Packet","Strength":"75","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45302030003030","GenericName":"IVACAFTOR PACKET 75 MG","NDC":"51167040001"},{"Id":403652,"FormularyType":"OHP","DrugName":"TRIKAFTA PAK 59.5MG","DosageForm":"THPK - Therapy Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4530990340B120","GenericName":"ELEXACAF-TEZACAF-IVACAF 80-40-60 MG& IVACAF 59.5MG THPK GRAN","NDC":"51167044501"},{"Id":403653,"FormularyType":"OHP","DrugName":"TRIKAFTA PAK 75MG","DosageForm":"THPK - Therapy Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4530990340B140","GenericName":"ELEXACAF-TEZACAF-IVACAF 100-50-75 MG& IVACAF 75MG THPK GRAN","NDC":"51167044601"},{"Id":403654,"FormularyType":"OHP","DrugName":"ORKAMBI GRA 150-188","DosageForm":"PACK - Packet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309902303020","GenericName":"LUMACAFTOR-IVACAFTOR GRANULES PACKET 150-188 MG","NDC":"51167050002"},{"Id":403655,"FormularyType":"OHP","DrugName":"KALYDECO PAK 25MG","DosageForm":"PACK - Packet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45302030003010","GenericName":"IVACAFTOR PACKET 25 MG","NDC":"51167060001"},{"Id":403656,"FormularyType":"OHP","DrugName":"SYMDEKO TAB 100-150","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4530990280B720","GenericName":"TEZACAFTOR-IVACAFTOR 100-150 MG & IVACAFTOR 150 MG TAB TBPK","NDC":"51167066101"},{"Id":403657,"FormularyType":"OHP","DrugName":"ORKAMBI TAB 100-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309902300310","GenericName":"LUMACAFTOR-IVACAFTOR TAB 100-125 MG","NDC":"51167070002"},{"Id":403658,"FormularyType":"OHP","DrugName":"KALYDECO GRA 13.4MG","DosageForm":"PACK - Packet","Strength":"13.4","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45302030003005","GenericName":"IVACAFTOR PACKET 13.4 MG","NDC":"51167077001"},{"Id":403659,"FormularyType":"OHP","DrugName":"KALYDECO GRA 5.8MG","DosageForm":"PACK - Packet","Strength":"5.8","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45302030003002","GenericName":"IVACAFTOR PACKET 5.8 MG","NDC":"51167078501"},{"Id":403660,"FormularyType":"OHP","DrugName":"ORKAMBI TAB 200-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309902300320","GenericName":"LUMACAFTOR-IVACAFTOR TAB 200-125 MG","NDC":"51167080901"},{"Id":403661,"FormularyType":"OHP","DrugName":"ORKAMBI GRA 100-125","DosageForm":"PACK - Packet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"CYSTIC FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45309902303010","GenericName":"LUMACAFTOR-IVACAFTOR GRANULES PACKET 100-125 MG","NDC":"51167090001"},{"Id":403662,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"51224000150"},{"Id":403663,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"51224001050"},{"Id":403664,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"51224001060"},{"Id":403665,"FormularyType":"OHP","DrugName":"ENU NUTRITIO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000502"},{"Id":403666,"FormularyType":"OHP","DrugName":"ENU NUTRITIO LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000503"},{"Id":403667,"FormularyType":"OHP","DrugName":"ENU COMPLETE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000523"},{"Id":403668,"FormularyType":"OHP","DrugName":"ENU COMPLETE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000524"},{"Id":403669,"FormularyType":"OHP","DrugName":"ENU COMPLETE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000525"},{"Id":403670,"FormularyType":"OHP","DrugName":"ENU COMPLETE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000526"},{"Id":403671,"FormularyType":"OHP","DrugName":"ULTRIENT 1.5 LIQ SAFE-T","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51272000530"},{"Id":403672,"FormularyType":"OHP","DrugName":"CVS ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"51316010250"},{"Id":403673,"FormularyType":"OHP","DrugName":"SMOOTH ANTAC CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"51316040540"},{"Id":403674,"FormularyType":"OHP","DrugName":"ALRGY & HIVE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"51316076703"},{"Id":403675,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"51393005200"},{"Id":403676,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"51393005225"},{"Id":403677,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"51407056405"},{"Id":403678,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"51407056490"},{"Id":403679,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"51407056505"},{"Id":403680,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"51407056590"},{"Id":403681,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"51407056605"},{"Id":403682,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"51407056690"},{"Id":403683,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"51407064101"},{"Id":403684,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"51407064110"},{"Id":403685,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"51407064190"},{"Id":403686,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"51407067301"},{"Id":403687,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"51407067302"},{"Id":403688,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"51407070101"},{"Id":403689,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"51407070105"},{"Id":403690,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"51407070202"},{"Id":403691,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"51407070206"},{"Id":403692,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"51407070211"},{"Id":403693,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"51407070222"},{"Id":403694,"FormularyType":"OHP","DrugName":"APREPITANT PAK 125 & 80","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020006320","GenericName":"APREPITANT CAPSULE THERAPY PACK 80 & 125 MG","NDC":"51407070403"},{"Id":403695,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"51407070701"},{"Id":403696,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"51407070801"},{"Id":403697,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"51407070901"},{"Id":403698,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"51407073725"},{"Id":403699,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"51407073750"},{"Id":403700,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"51407094301"},{"Id":403701,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"51407094305"},{"Id":403702,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"51407094390"},{"Id":403703,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"51407095010"},{"Id":403704,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"51407095090"},{"Id":403705,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"51407095110"},{"Id":403706,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"51407095190"},{"Id":403707,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.375 ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0.375","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107420","GenericName":"HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","NDC":"51525011501"},{"Id":403708,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"51525043101"},{"Id":403709,"FormularyType":"OHP","DrugName":"POLY GLYCOL LIQ 1450","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050300900","GenericName":"POLYETHYLENE GLYCOL 1450 LIQUID","NDC":"51552001904"},{"Id":403710,"FormularyType":"OHP","DrugName":"POLY GLYCOL LIQ 1450","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050300900","GenericName":"POLYETHYLENE GLYCOL 1450 LIQUID","NDC":"51552001906"},{"Id":403711,"FormularyType":"OHP","DrugName":"POLY GLYCOL LIQ 1450","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050300900","GenericName":"POLYETHYLENE GLYCOL 1450 LIQUID","NDC":"51552001908"},{"Id":403712,"FormularyType":"OHP","DrugName":"POLY GLYCOL LIQ 1450","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050300900","GenericName":"POLYETHYLENE GLYCOL 1450 LIQUID","NDC":"51552001909"},{"Id":403713,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"51552008806"},{"Id":403714,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"51552008809"},{"Id":403715,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"51552025806"},{"Id":403716,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"51552025808"},{"Id":403717,"FormularyType":"OHP","DrugName":"CHERRY SYP CONCENTR","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"51552029003"},{"Id":403718,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"51552068005"},{"Id":403719,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"51552068009"},{"Id":403720,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"51552069206"},{"Id":403721,"FormularyType":"OHP","DrugName":"SIMPLE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402030001200","GenericName":"SIMPLE - SYRUP","NDC":"51552069208"},{"Id":403722,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"51552069305"},{"Id":403723,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"51552080706"},{"Id":403724,"FormularyType":"OHP","DrugName":"CHERRY SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402020001200","GenericName":"CHERRY SYRUP","NDC":"51552080708"},{"Id":403725,"FormularyType":"OHP","DrugName":"GRAPE SYP","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"51552083105"},{"Id":403726,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"51552083605"},{"Id":403727,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"51552083609"},{"Id":403728,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"51552102802"},{"Id":403729,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"51552102804"},{"Id":403730,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"51552102805"},{"Id":403731,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"51552102806"},{"Id":403732,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"51552102807"},{"Id":403733,"FormularyType":"OHP","DrugName":"SYRSPEND SF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"51552107905"},{"Id":403734,"FormularyType":"OHP","DrugName":"SYRSPEND SF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"51552107909"},{"Id":403735,"FormularyType":"OHP","DrugName":"SYRSPEND SF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"51552112305"},{"Id":403736,"FormularyType":"OHP","DrugName":"SYRSPEND SF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"51552112309"},{"Id":403737,"FormularyType":"OHP","DrugName":"SYRSPEND SF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"51552116705"},{"Id":403738,"FormularyType":"OHP","DrugName":"SYRSPEND SF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"51552116709"},{"Id":403739,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS SWEETENE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552154405"},{"Id":403740,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS SWEETENE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552154407"},{"Id":403741,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS UNSWEETE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552154505"},{"Id":403742,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS UNSWEETE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552154507"},{"Id":403743,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS SWEETENE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552615101"},{"Id":403744,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS SWEETENE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552615102"},{"Id":403745,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS UNSWEETE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552615201"},{"Id":403746,"FormularyType":"OHP","DrugName":"UNISPEND ANH SUS UNSWEETE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51552615202"},{"Id":403747,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"51660002727"},{"Id":403748,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"51660002744"},{"Id":403749,"FormularyType":"OHP","DrugName":"NORLYROC TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"51660012786"},{"Id":403750,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"51660014030"},{"Id":403751,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"51660014190"},{"Id":403752,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"51660014290"},{"Id":403753,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"51660014390"},{"Id":403754,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"51660020005"},{"Id":403755,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"51660020030"},{"Id":403756,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"51660020090"},{"Id":403757,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"51660020421"},{"Id":403758,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"51660020469"},{"Id":403759,"FormularyType":"OHP","DrugName":"8 HOUR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"51660033601"},{"Id":403760,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"51660049221"},{"Id":403761,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"51660052601"},{"Id":403762,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"51660052605"},{"Id":403763,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"51660052630"},{"Id":403764,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"51660052631"},{"Id":403765,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"51660052653"},{"Id":403766,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"51660052669"},{"Id":403767,"FormularyType":"OHP","DrugName":"DELYLA TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"51660057286"},{"Id":403768,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"51660090430"},{"Id":403769,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"51660090530"},{"Id":403770,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093831"},{"Id":403771,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093854"},{"Id":403772,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093890"},{"Id":403773,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093901"},{"Id":403774,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093930"},{"Id":403775,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093953"},{"Id":403776,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093954"},{"Id":403777,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51660093990"},{"Id":403778,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"51660099830"},{"Id":403779,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"51660099855"},{"Id":403780,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"51663000503"},{"Id":403781,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"51663000507"},{"Id":403782,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"51663000508"},{"Id":403783,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"51663000517"},{"Id":403784,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"51663000520"},{"Id":403785,"FormularyType":"OHP","DrugName":"3 DAY VAGINL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"51672067080"},{"Id":403786,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"51672125801"},{"Id":403787,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"51672125802"},{"Id":403788,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"51672125803"},{"Id":403789,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"51672125806"},{"Id":403790,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"51672125901"},{"Id":403791,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"51672125902"},{"Id":403792,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"51672125903"},{"Id":403793,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"51672125906"},{"Id":403794,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"51672126301"},{"Id":403795,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"51672126302"},{"Id":403796,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"51672126303"},{"Id":403797,"FormularyType":"OHP","DrugName":"BETAMETH VAL CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020103710","GenericName":"BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","NDC":"51672126901"},{"Id":403798,"FormularyType":"OHP","DrugName":"BETAMETH VAL CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020103710","GenericName":"BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","NDC":"51672126906"},{"Id":403799,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"51672127001"},{"Id":403800,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"51672127003"},{"Id":403801,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"51672127007"},{"Id":403802,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"51672127201"},{"Id":403803,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"51672127202"},{"Id":403804,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"51672127203"},{"Id":403805,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"51672127302"},{"Id":403806,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"51672127304"},{"Id":403807,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"51672127401"},{"Id":403808,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"51672127406"},{"Id":403809,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51672127501"},{"Id":403810,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51672127502"},{"Id":403811,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51672127506"},{"Id":403812,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51672127507"},{"Id":403813,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"51672128201"},{"Id":403814,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"51672128202"},{"Id":403815,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"51672128208"},{"Id":403816,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"51672128401"},{"Id":403817,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"51672128402"},{"Id":403818,"FormularyType":"OHP","DrugName":"TRIAMCINOLON OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104210","GenericName":"TRIAMCINOLONE ACETONIDE OINT 0.1%","NDC":"51672128408"},{"Id":403819,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"51672128901"},{"Id":403820,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"51672128902"},{"Id":403821,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"51672129302"},{"Id":403822,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"51672129303"},{"Id":403823,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"51672129801"},{"Id":403824,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"51672129802"},{"Id":403825,"FormularyType":"OHP","DrugName":"KETOCONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045003710","GenericName":"KETOCONAZOLE CREAM 2%","NDC":"51672129803"},{"Id":403826,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"51672130005"},{"Id":403827,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"51672130009"},{"Id":403828,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"51672130100"},{"Id":403829,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"51672130102"},{"Id":403830,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"51672130104"},{"Id":403831,"FormularyType":"OHP","DrugName":"MOMETASONE SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082102010","GenericName":"MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","NDC":"51672130503"},{"Id":403832,"FormularyType":"OHP","DrugName":"MOMETASONE SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550082102010","GenericName":"MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","NDC":"51672130504"},{"Id":403833,"FormularyType":"OHP","DrugName":"BETA DIPROP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020053705","GenericName":"BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%","NDC":"51672131001"},{"Id":403834,"FormularyType":"OHP","DrugName":"BETA DIPROP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020053705","GenericName":"BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%","NDC":"51672131003"},{"Id":403835,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"51672131200"},{"Id":403836,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"51672131201"},{"Id":403837,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"51672131801"},{"Id":403838,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"51672131802"},{"Id":403839,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"51672131808"},{"Id":403840,"FormularyType":"OHP","DrugName":"ADAPAL/BEN P GEL 0.1-2.5%","DosageForm":"GEL - Gel","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90059902034020","GenericName":"ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5%","NDC":"51672136403"},{"Id":403841,"FormularyType":"OHP","DrugName":"FLUOCINOLONE SOL 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550055102005","GenericName":"FLUOCINOLONE ACETONIDE SOLN 0.01%","NDC":"51672136504"},{"Id":403842,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672138508"},{"Id":403843,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672138509"},{"Id":403844,"FormularyType":"OHP","DrugName":"AZELAIC ACID GEL 15%","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060010004020","GenericName":"AZELAIC ACID GEL 15%","NDC":"51672138903"},{"Id":403845,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"51672139902"},{"Id":403846,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"51672139903"},{"Id":403847,"FormularyType":"OHP","DrugName":"CLINDAMYCIN LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104105","GenericName":"CLINDAMYCIN PHOSPHATE LOTION 1%","NDC":"51672140004"},{"Id":403848,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"51672140700"},{"Id":403849,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"51672140709"},{"Id":403850,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672140908"},{"Id":403851,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672140909"},{"Id":403852,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"51672141103"},{"Id":403853,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"51672200101"},{"Id":403854,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"51672200102"},{"Id":403855,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51672200201"},{"Id":403856,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51672200202"},{"Id":403857,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1% VAG","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003705","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 1%","NDC":"51672200306"},{"Id":403858,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"51672201001"},{"Id":403859,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"51672201002"},{"Id":403860,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672201301"},{"Id":403861,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672201302"},{"Id":403862,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 0.5%","DosageForm":"OINT - Ointment","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004205","GenericName":"HYDROCORTISONE OINT 0.5%","NDC":"51672201502"},{"Id":403863,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"51672201802"},{"Id":403864,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"51672202701"},{"Id":403865,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"51672202702"},{"Id":403866,"FormularyType":"OHP","DrugName":"7 DAY VAGINA CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"51672203506"},{"Id":403867,"FormularyType":"OHP","DrugName":"3 DAY VAGINL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"51672206200"},{"Id":403868,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672206302"},{"Id":403869,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672206902"},{"Id":403870,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 CRE 4%","DosageForm":"CREA - Cream","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103720","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 4% (200 MG/5GM)","NDC":"51672207009"},{"Id":403871,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"51672207308"},{"Id":403872,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"51672207501"},{"Id":403873,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"51672207502"},{"Id":403874,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"51672208001"},{"Id":403875,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"51672208002"},{"Id":403876,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"51672208508"},{"Id":403877,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"51672209208"},{"Id":403878,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"51672210208"},{"Id":403879,"FormularyType":"OHP","DrugName":"FEVERALL INF SUP 80MG","DosageForm":"SUPP - Suppository","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005203","GenericName":"ACETAMINOPHEN SUPPOS 80 MG","NDC":"51672211400"},{"Id":403880,"FormularyType":"OHP","DrugName":"FEVERALL INF SUP 80MG","DosageForm":"SUPP - Suppository","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005203","GenericName":"ACETAMINOPHEN SUPPOS 80 MG","NDC":"51672211402"},{"Id":403881,"FormularyType":"OHP","DrugName":"FEVERALL INF SUP 80MG","DosageForm":"SUPP - Suppository","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005203","GenericName":"ACETAMINOPHEN SUPPOS 80 MG","NDC":"51672211404"},{"Id":403882,"FormularyType":"OHP","DrugName":"FEVERALL SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"51672211502"},{"Id":403883,"FormularyType":"OHP","DrugName":"FEVERALL SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"51672211504"},{"Id":403884,"FormularyType":"OHP","DrugName":"FEVERALL SUP 325MG","DosageForm":"SUPP - Suppository","Strength":"325","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005215","GenericName":"ACETAMINOPHEN SUPPOS 325 MG","NDC":"51672211602"},{"Id":403885,"FormularyType":"OHP","DrugName":"FEVERALL SUP 325MG","DosageForm":"SUPP - Suppository","Strength":"325","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005215","GenericName":"ACETAMINOPHEN SUPPOS 325 MG","NDC":"51672211604"},{"Id":403886,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"51672212001"},{"Id":403887,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"51672212002"},{"Id":403888,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672213001"},{"Id":403889,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672213008"},{"Id":403890,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"51672213108"},{"Id":403891,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"51672215001"},{"Id":403892,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"51672215006"},{"Id":403893,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003725","GenericName":"HYDROCORTISONE CREAM 2.5%","NDC":"51672300302"},{"Id":403894,"FormularyType":"OHP","DrugName":"HC/ACET ACID SOL 1-2%OTIC","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87300020102000","GenericName":"HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%","NDC":"51672300701"},{"Id":403895,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"51672400501"},{"Id":403896,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"51672400502"},{"Id":403897,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"51672400503"},{"Id":403898,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000120","GenericName":"ETODOLAC CAP 200 MG","NDC":"51672401601"},{"Id":403899,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000130","GenericName":"ETODOLAC CAP 300 MG","NDC":"51672401701"},{"Id":403900,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000310","GenericName":"ETODOLAC TAB 400 MG","NDC":"51672401801"},{"Id":403901,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"51672402201"},{"Id":403902,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"51672402301"},{"Id":403903,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"51672402502"},{"Id":403904,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"51672402504"},{"Id":403905,"FormularyType":"OHP","DrugName":"KETOCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11404040000310","GenericName":"KETOCONAZOLE TAB 200 MG","NDC":"51672402601"},{"Id":403906,"FormularyType":"OHP","DrugName":"KETOCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11404040000310","GenericName":"KETOCONAZOLE TAB 200 MG","NDC":"51672402606"},{"Id":403907,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"51672402701"},{"Id":403908,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"51672402703"},{"Id":403909,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"51672402707"},{"Id":403910,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"51672402801"},{"Id":403911,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"51672402803"},{"Id":403912,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"51672402807"},{"Id":403913,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"51672402901"},{"Id":403914,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"51672402903"},{"Id":403915,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"51672402907"},{"Id":403916,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"51672403001"},{"Id":403917,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"51672403003"},{"Id":403918,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"51672403007"},{"Id":403919,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"51672403101"},{"Id":403920,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"51672403103"},{"Id":403921,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"51672403107"},{"Id":403922,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"51672403201"},{"Id":403923,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"51672403203"},{"Id":403924,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"51672403301"},{"Id":403925,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"51672403303"},{"Id":403926,"FormularyType":"OHP","DrugName":"WARFARIN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"51672403401"},{"Id":403927,"FormularyType":"OHP","DrugName":"WARFARIN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"51672403403"},{"Id":403928,"FormularyType":"OHP","DrugName":"WARFARIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"51672403501"},{"Id":403929,"FormularyType":"OHP","DrugName":"WARFARIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"51672403503"},{"Id":403930,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000320","GenericName":"ETODOLAC TAB 500 MG","NDC":"51672403601"},{"Id":403931,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"51672403701"},{"Id":403932,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"51672403703"},{"Id":403933,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"51672403801"},{"Id":403934,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"51672403803"},{"Id":403935,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"51672404001"},{"Id":403936,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"51672404003"},{"Id":403937,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000505","GenericName":"CARBAMAZEPINE CHEW TAB 100 MG","NDC":"51672404101"},{"Id":403938,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000505","GenericName":"CARBAMAZEPINE CHEW TAB 100 MG","NDC":"51672404102"},{"Id":403939,"FormularyType":"OHP","DrugName":"ENALAPR/HCTZ TAB 5-12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802350305","GenericName":"ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG","NDC":"51672404501"},{"Id":403940,"FormularyType":"OHP","DrugName":"ENALAPR/HCTZ TAB 10-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802350310","GenericName":"ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG","NDC":"51672404601"},{"Id":403941,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"51672404704"},{"Id":403942,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE DIPROP","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"51672404801"},{"Id":403943,"FormularyType":"OHP","DrugName":"CLOTRIM/BETA CRE DIPROP","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902053710","GenericName":"CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","NDC":"51672404806"},{"Id":403944,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CHW 200MG","DosageForm":"CHEW - Tablet Chewable","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000510","GenericName":"CARBAMAZEPINE CHEW TAB 200 MG","NDC":"51672405001"},{"Id":403945,"FormularyType":"OHP","DrugName":"FLUOROURACIL SOL 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030002050","GenericName":"FLUOROURACIL SOLN 5%","NDC":"51672406301"},{"Id":403946,"FormularyType":"OHP","DrugName":"PHENYTOIN SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030001810","GenericName":"PHENYTOIN SUSP 125 MG/5ML","NDC":"51672406902"},{"Id":403947,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"51672407008"},{"Id":403948,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"51672408103"},{"Id":403949,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"51672408104"},{"Id":403950,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"51672409103"},{"Id":403951,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"51672411101"},{"Id":403952,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"51672411103"},{"Id":403953,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040004010","GenericName":"METRONIDAZOLE GEL 0.75%","NDC":"51672411606"},{"Id":403954,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"51672411704"},{"Id":403955,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"51672411709"},{"Id":403956,"FormularyType":"OHP","DrugName":"FLUOROURACIL CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030003730","GenericName":"FLUOROURACIL CREAM 5%","NDC":"51672411806"},{"Id":403957,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"51672412301"},{"Id":403958,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"51672412401"},{"Id":403959,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"51672412501"},{"Id":403960,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"51672413609"},{"Id":403961,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"51672414506"},{"Id":403962,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"51672414508"},{"Id":403963,"FormularyType":"OHP","DrugName":"PHENYTOIN CHW 50MG","DosageForm":"CHEW - Tablet Chewable","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030000505","GenericName":"PHENYTOIN CHEW TAB 50 MG","NDC":"51672414601"},{"Id":403964,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"51672417201"},{"Id":403965,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"51672417209"},{"Id":403966,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"51672418501"},{"Id":403967,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"51672418601"},{"Id":403968,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"51672420201"},{"Id":403969,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"51672420301"},{"Id":403970,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"51672422301"},{"Id":403971,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"51672422401"},{"Id":403972,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"51672422501"},{"Id":403973,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"51672422708"},{"Id":403974,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"51672424309"},{"Id":403975,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"51672424501"},{"Id":403976,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"51672424503"},{"Id":403977,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 12.5MG","DosageForm":"SUPP - Suppository","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105205","GenericName":"PROMETHAZINE HCL SUPPOS 12.5 MG","NDC":"51672529601"},{"Id":403978,"FormularyType":"OHP","DrugName":"PROMETHAZINE SUP 25MG","DosageForm":"SUPP - Suppository","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020105210","GenericName":"PROMETHAZINE HCL SUPPOS 25 MG","NDC":"51672529701"},{"Id":403979,"FormularyType":"OHP","DrugName":"CICLOPIROX SOL 8%","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030002020","GenericName":"CICLOPIROX SOLUTION 8%","NDC":"51672530200"},{"Id":403980,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"51672532108"},{"Id":403981,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672533001"},{"Id":403982,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672533002"},{"Id":403983,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51672533003"},{"Id":403984,"FormularyType":"OHP","DrugName":"AIMSCO MIS LUBRICAT","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"51709000605"},{"Id":403985,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"51754020301"},{"Id":403986,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"51754020302"},{"Id":403987,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"51754020304"},{"Id":403988,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"51754020401"},{"Id":403989,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"51754020404"},{"Id":403990,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"51754050001"},{"Id":403991,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"51754050103"},{"Id":403992,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"51754200104"},{"Id":403993,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 200/100","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"51754200401"},{"Id":403994,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 200/100","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"51754200404"},{"Id":403995,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"51754500101"},{"Id":403996,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"51754500104"},{"Id":403997,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"51754500105"},{"Id":403998,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"51754501101"},{"Id":403999,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"51754501104"},{"Id":404000,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"51754501201"},{"Id":404001,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"51754501204"},{"Id":404002,"FormularyType":"OHP","DrugName":"AJOVY INJ 225/1.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"225","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203020D520","GenericName":"FREMANEZUMAB-VFRM SUBCUTANEOUS SOLN AUTO-INJ 225 MG/1.5ML","NDC":"51759020210"},{"Id":404003,"FormularyType":"OHP","DrugName":"AJOVY INJ 225/1.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"225","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203020D520","GenericName":"FREMANEZUMAB-VFRM SUBCUTANEOUS SOLN AUTO-INJ 225 MG/1.5ML","NDC":"51759020211"},{"Id":404004,"FormularyType":"OHP","DrugName":"AJOVY INJ 225/1.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"225","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203020D520","GenericName":"FREMANEZUMAB-VFRM SUBCUTANEOUS SOLN AUTO-INJ 225 MG/1.5ML","NDC":"51759020222"},{"Id":404005,"FormularyType":"OHP","DrugName":"AJOVY INJ 225/1.5","DosageForm":"SOSY - Soln Pref Syr","Strength":"225","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770203020E520","GenericName":"FREMANEZUMAB-VFRM SUBCUTANEOUS SOLN PREF SYR 225 MG/1.5ML","NDC":"51759020410"},{"Id":404006,"FormularyType":"OHP","DrugName":"SIMLANDI KIT 20/0.2ML","DosageForm":"PSKT - Prefilled Syringe Kit","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001540F810","GenericName":"ADALIMUMAB-RYVK PREFILLED SYRINGE KIT 20 MG/0.2ML","NDC":"51759038622"},{"Id":404007,"FormularyType":"OHP","DrugName":"SIMLANDI 2PN INJ 40/0.4ML","DosageForm":"AJKT - Auto-injector Kit","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001540F520","GenericName":"ADALIMUMAB-RYVK AUTO-INJECTOR KIT 40 MG/0.4ML","NDC":"51759040202"},{"Id":404008,"FormularyType":"OHP","DrugName":"SIMLANDI 1PN KIT 40/0.4ML","DosageForm":"AJKT - Auto-injector Kit","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001540F520","GenericName":"ADALIMUMAB-RYVK AUTO-INJECTOR KIT 40 MG/0.4ML","NDC":"51759040217"},{"Id":404009,"FormularyType":"OHP","DrugName":"KIDS PROTEIN LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000300"},{"Id":404010,"FormularyType":"OHP","DrugName":"KIDS PROTEIN LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000301"},{"Id":404011,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000305"},{"Id":404012,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000306"},{"Id":404013,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000307"},{"Id":404014,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000308"},{"Id":404015,"FormularyType":"OHP","DrugName":"KIDS PROTEIN LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000310"},{"Id":404016,"FormularyType":"OHP","DrugName":"KIDS PROTEIN LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000312"},{"Id":404017,"FormularyType":"OHP","DrugName":"KIDS PROTEIN LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000313"},{"Id":404018,"FormularyType":"OHP","DrugName":"KIDS PROTEIN LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000315"},{"Id":404019,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000319"},{"Id":404020,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000320"},{"Id":404021,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000321"},{"Id":404022,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000322"},{"Id":404023,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000328"},{"Id":404024,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000329"},{"Id":404025,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000332"},{"Id":404026,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000333"},{"Id":404027,"FormularyType":"OHP","DrugName":"KIDS PLANT LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000351"},{"Id":404028,"FormularyType":"OHP","DrugName":"KIDS PLANT LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000352"},{"Id":404029,"FormularyType":"OHP","DrugName":"KIDS PLANT LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000356"},{"Id":404030,"FormularyType":"OHP","DrugName":"KIDS PLANT LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000385"},{"Id":404031,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000634"},{"Id":404032,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000639"},{"Id":404033,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000663"},{"Id":404034,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000674"},{"Id":404035,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000675"},{"Id":404036,"FormularyType":"OHP","DrugName":"ORGAIN KIDS LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000949"},{"Id":404037,"FormularyType":"OHP","DrugName":"ORGAIN KIDS LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51770000950"},{"Id":404038,"FormularyType":"OHP","DrugName":"EFFER-K TAB 25MEQ EF","DosageForm":"TBEF - Tablet Effervescent","Strength":"25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700020000810","GenericName":"POTASSIUM BICARBONATE EFFER TAB 25 MEQ","NDC":"51801000130"},{"Id":404039,"FormularyType":"OHP","DrugName":"EFFER-K TAB 25MEQ EF","DosageForm":"TBEF - Tablet Effervescent","Strength":"25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700020000810","GenericName":"POTASSIUM BICARBONATE EFFER TAB 25 MEQ","NDC":"51801000140"},{"Id":404040,"FormularyType":"OHP","DrugName":"EFFER-K TAB 25MEQ EF","DosageForm":"TBEF - Tablet Effervescent","Strength":"25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700020000810","GenericName":"POTASSIUM BICARBONATE EFFER TAB 25 MEQ","NDC":"51801000230"},{"Id":404041,"FormularyType":"OHP","DrugName":"EFFER-K TAB 25MEQ EF","DosageForm":"TBEF - Tablet Effervescent","Strength":"25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700020000810","GenericName":"POTASSIUM BICARBONATE EFFER TAB 25 MEQ","NDC":"51801000530"},{"Id":404042,"FormularyType":"OHP","DrugName":"EFFER-K TAB 25MEQ EF","DosageForm":"TBEF - Tablet Effervescent","Strength":"25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700020000810","GenericName":"POTASSIUM BICARBONATE EFFER TAB 25 MEQ","NDC":"51801000630"},{"Id":404043,"FormularyType":"OHP","DrugName":"EFFER-K TAB 25MEQ EF","DosageForm":"TBEF - Tablet Effervescent","Strength":"25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700020000810","GenericName":"POTASSIUM BICARBONATE EFFER TAB 25 MEQ","NDC":"51801000730"},{"Id":404044,"FormularyType":"OHP","DrugName":"PEDI PEPTIDE LIQ 1.5 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000620"},{"Id":404045,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.5","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000637"},{"Id":404046,"FormularyType":"OHP","DrugName":"PEPTIDE LIQ 1.5","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000646"},{"Id":404047,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.5","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000647"},{"Id":404048,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000663"},{"Id":404049,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0 CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000664"},{"Id":404050,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000666"},{"Id":404051,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000668"},{"Id":404052,"FormularyType":"OHP","DrugName":"KATE FARMS LIQ 1.0 CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000669"},{"Id":404053,"FormularyType":"OHP","DrugName":"PEDI PEPTIDE LIQ 1.5 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000687"},{"Id":404054,"FormularyType":"OHP","DrugName":"PEDI STANDAR LIQ 1.2 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000690"},{"Id":404055,"FormularyType":"OHP","DrugName":"PEDI STANDAR LIQ 1.2 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"51823000699"},{"Id":404056,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"51824000301"},{"Id":404057,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"51824003203"},{"Id":404058,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"51824003204"},{"Id":404059,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"51824003215"},{"Id":404060,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"51824004901"},{"Id":404061,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51824005001"},{"Id":404062,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN FRST AID","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"51824005201"},{"Id":404063,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN FRST AID","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"51824005214"},{"Id":404064,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN FRST AID","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"51824005225"},{"Id":404065,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"51824005601"},{"Id":404066,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"51824005736"},{"Id":404067,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"51824005801"},{"Id":404068,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"51824006001"},{"Id":404069,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"51824006101"},{"Id":404070,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"51824006301"},{"Id":404071,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"51824006401"},{"Id":404072,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"51824007401"},{"Id":404073,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"51824007601"},{"Id":404074,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"51824007701"},{"Id":404075,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"51824007801"},{"Id":404076,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51824009809"},{"Id":404077,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"51824009814"},{"Id":404078,"FormularyType":"OHP","DrugName":"LUTERA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"51862002801"},{"Id":404079,"FormularyType":"OHP","DrugName":"LUTERA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"51862002806"},{"Id":404080,"FormularyType":"OHP","DrugName":"LOW-OGESTREL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"51862056401"},{"Id":404081,"FormularyType":"OHP","DrugName":"LOW-OGESTREL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"51862056406"},{"Id":404082,"FormularyType":"OHP","DrugName":"CAMILA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"51862088401"},{"Id":404083,"FormularyType":"OHP","DrugName":"CAMILA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"51862088403"},{"Id":404084,"FormularyType":"OHP","DrugName":"ERRIN TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"51862088601"},{"Id":404085,"FormularyType":"OHP","DrugName":"ERRIN TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"51862088603"},{"Id":404086,"FormularyType":"OHP","DrugName":"MINERAL OIL HEAVY","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001750","GenericName":"MINERAL OIL (BULK)","NDC":"51927107400"},{"Id":404087,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"51927129100"},{"Id":404088,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"51927131300"},{"Id":404089,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"51927273300"},{"Id":404090,"FormularyType":"OHP","DrugName":"PCCA-PLUS SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51927322700"},{"Id":404091,"FormularyType":"OHP","DrugName":"PCCA SWEET SYP -SF","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"51927322800"},{"Id":404092,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"51927330000"},{"Id":404093,"FormularyType":"OHP","DrugName":"PCCA SYRUP SYP VEHICLE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"51927352100"},{"Id":404094,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"51927500400"},{"Id":404095,"FormularyType":"OHP","DrugName":"SUSPENDIT SUS ANHYDRS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"51927517600"},{"Id":404096,"FormularyType":"OHP","DrugName":"BASE A PEG POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"51927901300"},{"Id":404097,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"51991000590"},{"Id":404098,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"51991001406"},{"Id":404099,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"51991005301"},{"Id":404100,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"51991005305"},{"Id":404101,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"51991005401"},{"Id":404102,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"51991005405"},{"Id":404103,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"51991005501"},{"Id":404104,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"51991005505"},{"Id":404105,"FormularyType":"OHP","DrugName":"FERREX 150 CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"51991020301"},{"Id":404106,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"51991029201"},{"Id":404107,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"51991029205"},{"Id":404108,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"51991029301"},{"Id":404109,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"51991029305"},{"Id":404110,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"51991029401"},{"Id":404111,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"51991029405"},{"Id":404112,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000110","GenericName":"POMALIDOMIDE CAP 1 MG","NDC":"51991034221"},{"Id":404113,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000115","GenericName":"POMALIDOMIDE CAP 2 MG","NDC":"51991034321"},{"Id":404114,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000120","GenericName":"POMALIDOMIDE CAP 3 MG","NDC":"51991034421"},{"Id":404115,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000125","GenericName":"POMALIDOMIDE CAP 4 MG","NDC":"51991034621"},{"Id":404116,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"51991034805"},{"Id":404117,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"51991034806"},{"Id":404118,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"51991034905"},{"Id":404119,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"51991034906"},{"Id":404120,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"51991035005"},{"Id":404121,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"51991035006"},{"Id":404122,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"51991035105"},{"Id":404123,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"51991035106"},{"Id":404124,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"51991037906"},{"Id":404125,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"51991037960"},{"Id":404126,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"51991037999"},{"Id":404127,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"51991038006"},{"Id":404128,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"51991038060"},{"Id":404129,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"51991038099"},{"Id":404130,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"51991038106"},{"Id":404131,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"51991038160"},{"Id":404132,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"51991038199"},{"Id":404133,"FormularyType":"OHP","DrugName":"ESTRA/NORETH TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"51991047428"},{"Id":404134,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"51991052601"},{"Id":404135,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"51991062010"},{"Id":404136,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"51991062033"},{"Id":404137,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"51991062090"},{"Id":404138,"FormularyType":"OHP","DrugName":"ESTRA/NORETH TAB 0.5-0.1","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120305","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","NDC":"51991062328"},{"Id":404139,"FormularyType":"OHP","DrugName":"GRANISETRON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035100310","GenericName":"GRANISETRON HCL TAB 1 MG","NDC":"51991073520"},{"Id":404140,"FormularyType":"OHP","DrugName":"GRANISETRON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035100310","GenericName":"GRANISETRON HCL TAB 1 MG","NDC":"51991073532"},{"Id":404141,"FormularyType":"OHP","DrugName":"GRANISETRON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035100310","GenericName":"GRANISETRON HCL TAB 1 MG","NDC":"51991073599"},{"Id":404142,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"51991075910"},{"Id":404143,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"51991075933"},{"Id":404144,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"51991075990"},{"Id":404145,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 60MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107025","GenericName":"PROPRANOLOL HCL CAP ER 24HR 60 MG","NDC":"51991081701"},{"Id":404146,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 60MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107025","GenericName":"PROPRANOLOL HCL CAP ER 24HR 60 MG","NDC":"51991081705"},{"Id":404147,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 80MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107030","GenericName":"PROPRANOLOL HCL CAP ER 24HR 80 MG","NDC":"51991081801"},{"Id":404148,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 80MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107030","GenericName":"PROPRANOLOL HCL CAP ER 24HR 80 MG","NDC":"51991081805"},{"Id":404149,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107035","GenericName":"PROPRANOLOL HCL CAP ER 24HR 120 MG","NDC":"51991081901"},{"Id":404150,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107035","GenericName":"PROPRANOLOL HCL CAP ER 24HR 120 MG","NDC":"51991081905"},{"Id":404151,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 160MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107040","GenericName":"PROPRANOLOL HCL CAP ER 24HR 160 MG","NDC":"51991082001"},{"Id":404152,"FormularyType":"OHP","DrugName":"PROPRANOLOL CAP 160MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040107040","GenericName":"PROPRANOLOL HCL CAP ER 24HR 160 MG","NDC":"51991082005"},{"Id":404153,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"51991082128"},{"Id":404154,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"51991082133"},{"Id":404155,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"51991082199"},{"Id":404156,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"51991082228"},{"Id":404157,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"51991082233"},{"Id":404158,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"51991082299"},{"Id":404159,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"51991082328"},{"Id":404160,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"51991082333"},{"Id":404161,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"51991082399"},{"Id":404162,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"51991082428"},{"Id":404163,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"51991082433"},{"Id":404164,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"51991082499"},{"Id":404165,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"51991087733"},{"Id":404166,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"51991087790"},{"Id":404167,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"51991087833"},{"Id":404168,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"51991087890"},{"Id":404169,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"51991090601"},{"Id":404170,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"51991090701"},{"Id":404171,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"51991098506"},{"Id":404172,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"51991098560"},{"Id":404173,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"51991098599"},{"Id":404174,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007310","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 2 MG","NDC":"51991099028"},{"Id":404175,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007310","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 2 MG","NDC":"51991099077"},{"Id":404176,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007310","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 2 MG","NDC":"51991099099"},{"Id":404177,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 3MG","DosageForm":"TBSO - Tablet Soluble","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007320","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 3 MG","NDC":"51991099128"},{"Id":404178,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 3MG","DosageForm":"TBSO - Tablet Soluble","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007320","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 3 MG","NDC":"51991099177"},{"Id":404179,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 3MG","DosageForm":"TBSO - Tablet Soluble","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007320","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 3 MG","NDC":"51991099199"},{"Id":404180,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007340","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 5 MG","NDC":"51991099228"},{"Id":404181,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007340","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 5 MG","NDC":"51991099277"},{"Id":404182,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007340","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 5 MG","NDC":"51991099299"},{"Id":404183,"FormularyType":"OHP","DrugName":"THEO-24 CAP 200MG CR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007030","GenericName":"THEOPHYLLINE CAP ER 24HR 200 MG","NDC":"52244020010"},{"Id":404184,"FormularyType":"OHP","DrugName":"NOVAFERRUM DRO MV/IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002010","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**","NDC":"52304071650"},{"Id":404185,"FormularyType":"OHP","DrugName":"KETOGEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"52404000400"},{"Id":404186,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"52422031601"},{"Id":404187,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"52422032401"},{"Id":404188,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"52422033401"},{"Id":404189,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 25MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102160","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 25 MG/ML (BASE EQUIVALENT)","NDC":"52536010405"},{"Id":404190,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"52536010605"},{"Id":404191,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 25MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102160","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 25 MG/ML (BASE EQUIVALENT)","NDC":"52536010710"},{"Id":404192,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"52536010810"},{"Id":404193,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 100MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107015","GenericName":"VERAPAMIL HCL CAP ER 24HR 100 MG","NDC":"52536048537"},{"Id":404194,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 200MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"200","BrandVsGeneric":"N","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107030","GenericName":"VERAPAMIL HCL CAP ER 24HR 200 MG","NDC":"52536048637"},{"Id":404195,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"N","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107040","GenericName":"VERAPAMIL HCL CAP ER 24HR 300 MG","NDC":"52536048737"},{"Id":404196,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"52536050001"},{"Id":404197,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100305","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 5 MG","NDC":"52536050003"},{"Id":404198,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"52536051001"},{"Id":404199,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"52536051003"},{"Id":404200,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"52536062501"},{"Id":404201,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"52536062510"},{"Id":404202,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 120MG SR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107020","GenericName":"VERAPAMIL HCL CAP ER 24HR 120 MG","NDC":"52536088001"},{"Id":404203,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 180MG SR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107025","GenericName":"VERAPAMIL HCL CAP ER 24HR 180 MG","NDC":"52536088201"},{"Id":404204,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 240MG SR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107035","GenericName":"VERAPAMIL HCL CAP ER 24HR 240 MG","NDC":"52536088401"},{"Id":404205,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 360MG SR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"N","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107045","GenericName":"VERAPAMIL HCL CAP ER 24HR 360 MG","NDC":"52536088601"},{"Id":404206,"FormularyType":"OHP","DrugName":"AMETHYST TAB 90-20MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25994002350320","GenericName":"LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","NDC":"52544029531"},{"Id":404207,"FormularyType":"OHP","DrugName":"HM ULTICARE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"52569013302"},{"Id":404208,"FormularyType":"OHP","DrugName":"HM INSULIN S MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"52569013305"},{"Id":404209,"FormularyType":"OHP","DrugName":"HM INSULIN S MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"52569013306"},{"Id":404210,"FormularyType":"OHP","DrugName":"HM STERILE PAD 2X2 8PLY","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"52569013341"},{"Id":404211,"FormularyType":"OHP","DrugName":"HM FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"52569013960"},{"Id":404212,"FormularyType":"OHP","DrugName":"HM ENEMA ENE R-T-U","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"52569013971"},{"Id":404213,"FormularyType":"OHP","DrugName":"ULTICARE MIC MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"52569014238"},{"Id":404214,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"52569014239"},{"Id":404215,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"52569014240"},{"Id":404216,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"52569014389"},{"Id":404217,"FormularyType":"OHP","DrugName":"GRASTEK SUB 2800BAU","DosageForm":"SUBL - Tab Sublingual","Strength":"2800","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20100048000740","GenericName":"TIMOTHY GRASS POLLEN ALLERGEN EXT SL TAB 2800 BAU","NDC":"52709150101"},{"Id":404218,"FormularyType":"OHP","DrugName":"GRASTEK SUB 2800BAU","DosageForm":"SUBL - Tab Sublingual","Strength":"2800","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20100048000740","GenericName":"TIMOTHY GRASS POLLEN ALLERGEN EXT SL TAB 2800 BAU","NDC":"52709150103"},{"Id":404219,"FormularyType":"OHP","DrugName":"RAGWITEK SUB","DosageForm":"SUBL - Tab Sublingual","Strength":"12","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20100060200720","GenericName":"SHORT RAGWEED POLLEN ALLERGEN EXTRACT SL TAB 12 AMB A 1-U","NDC":"52709160101"},{"Id":404220,"FormularyType":"OHP","DrugName":"RAGWITEK SUB","DosageForm":"SUBL - Tab Sublingual","Strength":"12","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20100060200720","GenericName":"SHORT RAGWEED POLLEN ALLERGEN EXTRACT SL TAB 12 AMB A 1-U","NDC":"52709160103"},{"Id":404221,"FormularyType":"OHP","DrugName":"ODACTRA SUB","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20109902220740","GenericName":"*DUST MITE MIXED EXT SL TAB 12 SQ-HDM***","NDC":"52709170101"},{"Id":404222,"FormularyType":"OHP","DrugName":"ODACTRA SUB","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20109902220740","GenericName":"*DUST MITE MIXED EXT SL TAB 12 SQ-HDM***","NDC":"52709170103"},{"Id":404223,"FormularyType":"OHP","DrugName":"CONCEPT OB CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512058000150","GenericName":"*PRENATAL W/O A W/FE FUM-FE POLY-FA CAP 130-92.4-1 MG***","NDC":"52747062030"},{"Id":404224,"FormularyType":"OHP","DrugName":"SOL CARB POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"52766000701"},{"Id":404225,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000307","GenericName":"PRIMIDONE TAB 125 MG","NDC":"52817011710"},{"Id":404226,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"52817018000"},{"Id":404227,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"52817018010"},{"Id":404228,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"52817018100"},{"Id":404229,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"52817018110"},{"Id":404230,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"52817018200"},{"Id":404231,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"52817018210"},{"Id":404232,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"52817020010"},{"Id":404233,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"52817020110"},{"Id":404234,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"52817021010"},{"Id":404235,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"52817021050"},{"Id":404236,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"52817023510"},{"Id":404237,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"52817023530"},{"Id":404238,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"52817025000"},{"Id":404239,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"52817025010"},{"Id":404240,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 37.5MG","DosageForm":"TABS - Tablet","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100307","GenericName":"METOPROLOL TARTRATE TAB 37.5 MG","NDC":"52817025110"},{"Id":404241,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"52817025200"},{"Id":404242,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"52817025210"},{"Id":404243,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100312","GenericName":"METOPROLOL TARTRATE TAB 75 MG","NDC":"52817025310"},{"Id":404244,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"52817025400"},{"Id":404245,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"52817025410"},{"Id":404246,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"52817026010"},{"Id":404247,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"52817026050"},{"Id":404248,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"52817027010"},{"Id":404249,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"52817027030"},{"Id":404250,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"52817027110"},{"Id":404251,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"52817027130"},{"Id":404252,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"52817029590"},{"Id":404253,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000308","GenericName":"BACLOFEN TAB 15 MG","NDC":"52817031810"},{"Id":404254,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"52817031910"},{"Id":404255,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"52817032000"},{"Id":404256,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"52817032010"},{"Id":404257,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"52817032050"},{"Id":404258,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"52817032100"},{"Id":404259,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"52817032110"},{"Id":404260,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"52817032150"},{"Id":404261,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"52817032310"},{"Id":404262,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"52817032410"},{"Id":404263,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"52817032510"},{"Id":404264,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"52817033010"},{"Id":404265,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"52817033050"},{"Id":404266,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"52817033200"},{"Id":404267,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"52817033210"},{"Id":404268,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"52817033250"},{"Id":404269,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 37.5MG","DosageForm":"TABS - Tablet","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100307","GenericName":"METOPROLOL TARTRATE TAB 37.5 MG","NDC":"52817035810"},{"Id":404270,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100312","GenericName":"METOPROLOL TARTRATE TAB 75 MG","NDC":"52817035910"},{"Id":404271,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"52817036000"},{"Id":404272,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"52817036010"},{"Id":404273,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"52817036100"},{"Id":404274,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"52817036110"},{"Id":404275,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"52817036200"},{"Id":404276,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"52817036210"},{"Id":404277,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000303","GenericName":"GLIPIZIDE TAB 2.5 MG","NDC":"52817038510"},{"Id":404278,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"52817039010"},{"Id":404279,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"52817039050"},{"Id":404280,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"52817039100"},{"Id":404281,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"52817039110"},{"Id":404282,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"52817039150"},{"Id":404283,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"52817039200"},{"Id":404284,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"52817039210"},{"Id":404285,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"52817039250"},{"Id":404286,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"52817081154"},{"Id":404287,"FormularyType":"OHP","DrugName":"ACETIC ACID SOL 2% OTIC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC AGENTS - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87400010102010","GenericName":"ACETIC ACID OTIC SOLN 2%","NDC":"52817081615"},{"Id":404288,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"52817082415"},{"Id":404289,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"52817082445"},{"Id":404290,"FormularyType":"OHP","DrugName":"LEVOCARNITIN SOL 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045102010","GenericName":"LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)","NDC":"52817083004"},{"Id":404291,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"52817084016"},{"Id":404292,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"52817085001"},{"Id":404293,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"52817085030"},{"Id":404294,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"52817085101"},{"Id":404295,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"52817085130"},{"Id":404296,"FormularyType":"OHP","DrugName":"SEPHIENCE POW 250MG","DosageForm":"PACK - Packet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908568003020","GenericName":"SEPIAPTERIN POWDER PACKET 250 MG","NDC":"52856020101"},{"Id":404297,"FormularyType":"OHP","DrugName":"SEPHIENCE POW 250MG","DosageForm":"PACK - Packet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908568003020","GenericName":"SEPIAPTERIN POWDER PACKET 250 MG","NDC":"52856020103"},{"Id":404298,"FormularyType":"OHP","DrugName":"SEPHIENCE POW 1000MG","DosageForm":"PACK - Packet","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908568003040","GenericName":"SEPIAPTERIN POWDER PACKET 1000 MG","NDC":"52856030101"},{"Id":404299,"FormularyType":"OHP","DrugName":"SEPHIENCE POW 1000MG","DosageForm":"PACK - Packet","Strength":"1000","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908568003040","GenericName":"SEPIAPTERIN POWDER PACKET 1000 MG","NDC":"52856030103"},{"Id":404300,"FormularyType":"OHP","DrugName":"VCF VAGINAL GEL CONTRACE","DosageForm":"GEL - Gel","Strength":"4","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"SPERMICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55300010004040","GenericName":"NONOXYNOL-9 GEL 4%","NDC":"52925051210"},{"Id":404301,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"52982000614"},{"Id":404302,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"52982000615"},{"Id":404303,"FormularyType":"OHP","DrugName":"BETA HC LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"53062001202"},{"Id":404304,"FormularyType":"OHP","DrugName":"BETASAL SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"53062001416"},{"Id":404305,"FormularyType":"OHP","DrugName":"BETATEMP SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"53062002704"},{"Id":404306,"FormularyType":"OHP","DrugName":"NIZORAL SHA 1%","DosageForm":"SHAM - Shampoo","Strength":"1","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004505","GenericName":"KETOCONAZOLE SHAMPOO 1%","NDC":"53076019233"},{"Id":404307,"FormularyType":"OHP","DrugName":"NIZORAL SHA 1%","DosageForm":"SHAM - Shampoo","Strength":"1","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004505","GenericName":"KETOCONAZOLE SHAMPOO 1%","NDC":"53076019240"},{"Id":404308,"FormularyType":"OHP","DrugName":"NIZORAL PSOR SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"53076020264"},{"Id":404309,"FormularyType":"OHP","DrugName":"SAM-E.P.A. CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"53191007301"},{"Id":404310,"FormularyType":"OHP","DrugName":"MELATONIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000150","GenericName":"MELATONIN CAP 5 MG","NDC":"53191021401"},{"Id":404311,"FormularyType":"OHP","DrugName":"MELATONIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000120","GenericName":"MELATONIN CAP 1 MG","NDC":"53191022601"},{"Id":404312,"FormularyType":"OHP","DrugName":"MELATONIN CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000140","GenericName":"MELATONIN CAP 3 MG","NDC":"53191022701"},{"Id":404313,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"53191024401"},{"Id":404314,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"53191024425"},{"Id":404315,"FormularyType":"OHP","DrugName":"D3-50 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"53191036201"},{"Id":404316,"FormularyType":"OHP","DrugName":"D3-50 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"53191036212"},{"Id":404317,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"53191045401"},{"Id":404318,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"53191045425"},{"Id":404319,"FormularyType":"OHP","DrugName":"D3-50 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"53191048901"},{"Id":404320,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307501"},{"Id":404321,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307502"},{"Id":404322,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307503"},{"Id":404323,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307504"},{"Id":404324,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307505"},{"Id":404325,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307506"},{"Id":404326,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"53225307507"},{"Id":404327,"FormularyType":"OHP","DrugName":"VELTASSA POW 1GM","DosageForm":"PACK - Packet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203005","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 1 GM (BASE EQ)","NDC":"53436001001"},{"Id":404328,"FormularyType":"OHP","DrugName":"VELTASSA POW 1GM","DosageForm":"PACK - Packet","Strength":"1","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203005","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 1 GM (BASE EQ)","NDC":"53436001060"},{"Id":404329,"FormularyType":"OHP","DrugName":"VELTASSA POW 8.4GM","DosageForm":"PACK - Packet","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203020","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 8.4 GM (BASE EQ)","NDC":"53436008401"},{"Id":404330,"FormularyType":"OHP","DrugName":"VELTASSA POW 8.4GM","DosageForm":"PACK - Packet","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203020","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 8.4 GM (BASE EQ)","NDC":"53436008404"},{"Id":404331,"FormularyType":"OHP","DrugName":"VELTASSA POW 8.4GM","DosageForm":"PACK - Packet","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203020","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 8.4 GM (BASE EQ)","NDC":"53436008430"},{"Id":404332,"FormularyType":"OHP","DrugName":"VELTASSA POW 8.4GM","DosageForm":"PACK - Packet","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203020","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 8.4 GM (BASE EQ)","NDC":"53436008492"},{"Id":404333,"FormularyType":"OHP","DrugName":"VELTASSA POW 16.8GM","DosageForm":"PACK - Packet","Strength":"16.8","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203030","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 16.8 GM (BASE EQ)","NDC":"53436016801"},{"Id":404334,"FormularyType":"OHP","DrugName":"VELTASSA POW 16.8GM","DosageForm":"PACK - Packet","Strength":"16.8","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203030","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 16.8 GM (BASE EQ)","NDC":"53436016830"},{"Id":404335,"FormularyType":"OHP","DrugName":"VELTASSA POW 25.2GM","DosageForm":"PACK - Packet","Strength":"25.2","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203040","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 25.2 GM (BASE EQ)","NDC":"53436025201"},{"Id":404336,"FormularyType":"OHP","DrugName":"VELTASSA POW 25.2GM","DosageForm":"PACK - Packet","Strength":"25.2","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450060203040","GenericName":"PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 25.2 GM (BASE EQ)","NDC":"53436025230"},{"Id":404337,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"53489011802"},{"Id":404338,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"53489011805"},{"Id":404339,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"53489011902"},{"Id":404340,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"53489011905"},{"Id":404341,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"53489012001"},{"Id":404342,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"53489012002"},{"Id":404343,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"53489012005"},{"Id":404344,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"53489012060"},{"Id":404345,"FormularyType":"OHP","DrugName":"QUINIDINE GL TAB 324MG CR","DosageForm":"TBCR - Tablet ER","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100030100403","GenericName":"QUINIDINE GLUCONATE TAB ER 324 MG","NDC":"53489014101"},{"Id":404346,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"53489014301"},{"Id":404347,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"53489014305"},{"Id":404348,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"53489014310"},{"Id":404349,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"53489014401"},{"Id":404350,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"53489014405"},{"Id":404351,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"53489014410"},{"Id":404352,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"53489014501"},{"Id":404353,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"53489014505"},{"Id":404354,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"53489014601"},{"Id":404355,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"53489014605"},{"Id":404356,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"53489015601"},{"Id":404357,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"53489015605"},{"Id":404358,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"53489015610"},{"Id":404359,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"53489015701"},{"Id":404360,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"53489015705"},{"Id":404361,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"53489015710"},{"Id":404362,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"53489017601"},{"Id":404363,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"53489017605"},{"Id":404364,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"53489017701"},{"Id":404365,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"53489017705"},{"Id":404366,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"53489021501"},{"Id":404367,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"53489021510"},{"Id":404368,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"53489021601"},{"Id":404369,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"53489021610"},{"Id":404370,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"53489021701"},{"Id":404371,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"53489032801"},{"Id":404372,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"53489032805"},{"Id":404373,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"53489032806"},{"Id":404374,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"53489032807"},{"Id":404375,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"53489032901"},{"Id":404376,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"53489032905"},{"Id":404377,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"53489032906"},{"Id":404378,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"53489032907"},{"Id":404379,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000305","GenericName":"MINOXIDIL TAB 2.5 MG","NDC":"53489038601"},{"Id":404380,"FormularyType":"OHP","DrugName":"MINOXIDIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400020000310","GenericName":"MINOXIDIL TAB 10 MG","NDC":"53489038701"},{"Id":404381,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"53489047801"},{"Id":404382,"FormularyType":"OHP","DrugName":"SULINDAC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000305","GenericName":"SULINDAC TAB 150 MG","NDC":"53489047805"},{"Id":404383,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"53489047901"},{"Id":404384,"FormularyType":"OHP","DrugName":"SULINDAC TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100080000310","GenericName":"SULINDAC TAB 200 MG","NDC":"53489047905"},{"Id":404385,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"53489052910"},{"Id":404386,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100302","GenericName":"DOXYCYCLINE HYCLATE TAB 20 MG","NDC":"53489064701"},{"Id":404387,"FormularyType":"OHP","DrugName":"OVEGA-3 CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"53530000502"},{"Id":404388,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"53598000301"},{"Id":404389,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"53598000310"},{"Id":404390,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"53598000401"},{"Id":404391,"FormularyType":"OHP","DrugName":"DICYCLOMINE SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010102050","GenericName":"DICYCLOMINE HCL ORAL SOLN 10 MG/5ML","NDC":"53703080016"},{"Id":404392,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"53746010901"},{"Id":404393,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"53746010905"},{"Id":404394,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"53746010910"},{"Id":404395,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"53746011001"},{"Id":404396,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"53746011005"},{"Id":404397,"FormularyType":"OHP","DrugName":"HYDROCOD/IBU TAB 7.5-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702500320","GenericName":"HYDROCODONE-IBUPROFEN TAB 7.5-200 MG","NDC":"53746014501"},{"Id":404398,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"53746016960"},{"Id":404399,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"53746017360"},{"Id":404400,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"53746020301"},{"Id":404401,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"53746020305"},{"Id":404402,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"53746020401"},{"Id":404403,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"53746020405"},{"Id":404404,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"53746027101"},{"Id":404405,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"53746027105"},{"Id":404406,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"53746027201"},{"Id":404407,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"53746027205"},{"Id":404408,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"53746036101"},{"Id":404409,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"53746036110"},{"Id":404410,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"53746044101"},{"Id":404411,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"53746044110"},{"Id":404412,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"53746044201"},{"Id":404413,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"53746044210"},{"Id":404414,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"53746046560"},{"Id":404415,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"53746051101"},{"Id":404416,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"53746051105"},{"Id":404417,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"53746051110"},{"Id":404418,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"53746051401"},{"Id":404419,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"53746051405"},{"Id":404420,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"53746051501"},{"Id":404421,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"53746051505"},{"Id":404422,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"53746052101"},{"Id":404423,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"53746052110"},{"Id":404424,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100315","GenericName":"PROMETHAZINE HCL TAB 50 MG","NDC":"53746052201"},{"Id":404425,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"53746054201"},{"Id":404426,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"53746054205"},{"Id":404427,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"53746054401"},{"Id":404428,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"53746054405"},{"Id":404429,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"53746054501"},{"Id":404430,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100310","GenericName":"BETHANECHOL CHLORIDE TAB 5 MG","NDC":"53746057101"},{"Id":404431,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"53746057201"},{"Id":404432,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"53746057301"},{"Id":404433,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100340","GenericName":"BETHANECHOL CHLORIDE TAB 50 MG","NDC":"53746057401"},{"Id":404434,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"53746061701"},{"Id":404435,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"53746061705"},{"Id":404436,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"53746061710"},{"Id":404437,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"53746064101"},{"Id":404438,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"53746064201"},{"Id":404439,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"53746064301"},{"Id":404440,"FormularyType":"OHP","DrugName":"ACEBUTOLOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200010100105","GenericName":"ACEBUTOLOL HCL CAP 200 MG","NDC":"53746066901"},{"Id":404441,"FormularyType":"OHP","DrugName":"ACEBUTOLOL CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200010100110","GenericName":"ACEBUTOLOL HCL CAP 400 MG","NDC":"53746067001"},{"Id":404442,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"53746071101"},{"Id":404443,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"53746071301"},{"Id":404444,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"53746073490"},{"Id":404445,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"53746073518"},{"Id":404446,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"53746073590"},{"Id":404447,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100305","GenericName":"PROMETHAZINE HCL TAB 12.5 MG","NDC":"53746074501"},{"Id":404448,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"53746075101"},{"Id":404449,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"53746075105"},{"Id":404450,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"53746075201"},{"Id":404451,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"53746075205"},{"Id":404452,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"53746075301"},{"Id":404453,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"53746075305"},{"Id":404454,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"53746075401"},{"Id":404455,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"53746075405"},{"Id":404456,"FormularyType":"OHP","DrugName":"BUDESONIDE CAP 3MG DR","DosageForm":"CPEP - Capsule DR Part","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100012006720","GenericName":"BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","NDC":"53746077810"},{"Id":404457,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"53746083153"},{"Id":404458,"FormularyType":"OHP","DrugName":"EASY TOUCH MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146341","GenericName":"INSULIN PEN NEEDLE 30 G X 6 MM (1/4\" OR 15/64\")","NDC":"53747000370"},{"Id":404459,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"53747000371"},{"Id":404460,"FormularyType":"OHP","DrugName":"ONETOUCH DEL MIS PLUS 33G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"53885000810"},{"Id":404461,"FormularyType":"OHP","DrugName":"ONETOUCH DEL MIS PLUS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"53885001110"},{"Id":404462,"FormularyType":"OHP","DrugName":"ONETOUCH DEL MIS LANC DEV","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202027006300","GenericName":"*LANCET DEVICES***","NDC":"53885097301"},{"Id":404463,"FormularyType":"OHP","DrugName":"PENTASA CAP 250MG CR","DosageForm":"CPCR - Capsule ER","Strength":"250","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000210","GenericName":"MESALAMINE CAP ER 250 MG","NDC":"54092018981"},{"Id":404464,"FormularyType":"OHP","DrugName":"PENTASA CAP 500MG CR","DosageForm":"CPCR - Capsule ER","Strength":"500","BrandVsGeneric":"O","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000220","GenericName":"MESALAMINE CAP ER 500 MG","NDC":"54092019112"},{"Id":404465,"FormularyType":"OHP","DrugName":"ZUBSOLV SUB 11.4-2.9","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200760","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 11.4-2.9 MG (BASE EQ)","NDC":"54123011430"},{"Id":404466,"FormularyType":"OHP","DrugName":"ZUBSOLV SUB 0.7-0.18","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200710","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 0.7-0.18 MG (BASE EQ)","NDC":"54123090730"},{"Id":404467,"FormularyType":"OHP","DrugName":"ZUBSOLV SUB 1.4-0.36","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200715","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 1.4-0.36 MG (BASE EQ)","NDC":"54123091430"},{"Id":404468,"FormularyType":"OHP","DrugName":"ZUBSOLV SUB 2.9-0.71","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200725","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2.9-0.71 MG (BASE EQ)","NDC":"54123092930"},{"Id":404469,"FormularyType":"OHP","DrugName":"ZUBSOLV SUB 5.7-1.4","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200732","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 5.7-1.4 MG (BASE EQ)","NDC":"54123095730"},{"Id":404470,"FormularyType":"OHP","DrugName":"ZUBSOLV SUB 8.6-2.1","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200745","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8.6-2.1 MG (BASE EQ)","NDC":"54123098630"},{"Id":404471,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"54257027406"},{"Id":404472,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"54257027425"},{"Id":404473,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"54257057303"},{"Id":404474,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"54257090206"},{"Id":404475,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"54288013501"},{"Id":404476,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"54295030815"},{"Id":404477,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"54295030824"},{"Id":404478,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"54295030825"},{"Id":404479,"FormularyType":"OHP","DrugName":"UREA CRE 39%","DosageForm":"CREA - Cream","Strength":"39","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003724","GenericName":"UREA CREAM 39%","NDC":"54295031118"},{"Id":404480,"FormularyType":"OHP","DrugName":"UREA LOT 40%","DosageForm":"LOTN - Lotion","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080004140","GenericName":"UREA LOTION 40%","NDC":"54295031218"},{"Id":404481,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"54458000022"},{"Id":404482,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"54458021360"},{"Id":404483,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"54458032334"},{"Id":404484,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"54458032344"},{"Id":404485,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"54458032345"},{"Id":404486,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"54458032355"},{"Id":404487,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"54458065710"},{"Id":404488,"FormularyType":"OHP","DrugName":"OMEGA 3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"54458073950"},{"Id":404489,"FormularyType":"OHP","DrugName":"MATULANE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700050100105","GenericName":"PROCARBAZINE HCL CAP 50 MG","NDC":"54482005401"},{"Id":404490,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 450MG","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"54629000101"},{"Id":404491,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"54629001162"},{"Id":404492,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB /VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"54629001681"},{"Id":404493,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"54629001893"},{"Id":404494,"FormularyType":"OHP","DrugName":"CHILDREN VIT CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"54629005001"},{"Id":404495,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"54629005024"},{"Id":404496,"FormularyType":"OHP","DrugName":"NIACIN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000320","GenericName":"NIACIN TAB 50 MG","NDC":"54629005101"},{"Id":404497,"FormularyType":"OHP","DrugName":"PRENATAL/FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000315","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG***","NDC":"54629005201"},{"Id":404498,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"54629005701"},{"Id":404499,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"54629005801"},{"Id":404500,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"54629006301"},{"Id":404501,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"54629006310"},{"Id":404502,"FormularyType":"OHP","DrugName":"DSS CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"54629006801"},{"Id":404503,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"54629006900"},{"Id":404504,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB /VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"54629007200"},{"Id":404505,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"54629009310"},{"Id":404506,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"54629009330"},{"Id":404507,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"54629009332"},{"Id":404508,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"54629010505"},{"Id":404509,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"54629011090"},{"Id":404510,"FormularyType":"OHP","DrugName":"FULL SPECT TAB B/ VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"54629012691"},{"Id":404511,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"54629012800"},{"Id":404512,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"54629012810"},{"Id":404513,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"54629016801"},{"Id":404514,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"54629026001"},{"Id":404515,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"54629037701"},{"Id":404516,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"54629037702"},{"Id":404517,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"54629041120"},{"Id":404518,"FormularyType":"OHP","DrugName":"CHILDREN VIT CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"54629050102"},{"Id":404519,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"54629050233"},{"Id":404520,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG CR","DosageForm":"TBCR - Tablet ER","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000420","GenericName":"MELATONIN TAB ER 3 MG","NDC":"54629050260"},{"Id":404521,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"54629058001"},{"Id":404522,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"54629058501"},{"Id":404523,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"54629058605"},{"Id":404524,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"54629060199"},{"Id":404525,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"54629060900"},{"Id":404526,"FormularyType":"OHP","DrugName":"MELATONIN SUB 5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000740","GenericName":"MELATONIN SL TAB 5 MG","NDC":"54629061500"},{"Id":404527,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"54629063001"},{"Id":404528,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000318","GenericName":"FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON)","NDC":"54629064501"},{"Id":404529,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"54629065002"},{"Id":404530,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"54629068101"},{"Id":404531,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"54629068110"},{"Id":404532,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"54629068202"},{"Id":404533,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"54629068301"},{"Id":404534,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"54629068401"},{"Id":404535,"FormularyType":"OHP","DrugName":"CALCIUM CARB CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000515","GenericName":"CALCIUM CARBONATE CHEW TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"54629068701"},{"Id":404536,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"54629070090"},{"Id":404537,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG TR","DosageForm":"TBCR - Tablet ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000440","GenericName":"NIACIN TAB ER 250 MG","NDC":"54629070901"},{"Id":404538,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG TR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"54629071101"},{"Id":404539,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"54629071201"},{"Id":404540,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"54629071500"},{"Id":404541,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"54629073303"},{"Id":404542,"FormularyType":"OHP","DrugName":"LIQ CA/VIT D CAP 600MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630150","GenericName":"CALCIUM CARBONATE-VITAMIN D CAP 600 MG-5 MCG (200 UNIT)","NDC":"54629073500"},{"Id":404543,"FormularyType":"OHP","DrugName":"VITAMIN D3 DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"54629077232"},{"Id":404544,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"54629077401"},{"Id":404545,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"54629077402"},{"Id":404546,"FormularyType":"OHP","DrugName":"SLOW IRON TAB 160MG ER","DosageForm":"TBCR - Tablet ER","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100410","GenericName":"FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT)","NDC":"54629077460"},{"Id":404547,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 5GR","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"54629077500"},{"Id":404548,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"54629079854"},{"Id":404549,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 2MEQ","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000310","GenericName":"POTASSIUM GLUCONATE TAB 2 MEQ","NDC":"54629085001"},{"Id":404550,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"54629089309"},{"Id":404551,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"54629089821"},{"Id":404552,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"54629090970"},{"Id":404553,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"54629090980"},{"Id":404554,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"54629092910"},{"Id":404555,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"54629093050"},{"Id":404556,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"54629794101"},{"Id":404557,"FormularyType":"OHP","DrugName":"MELATONIN TR TAB 1MG","DosageForm":"TBCR - Tablet ER","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000405","GenericName":"MELATONIN TAB ER 1 MG","NDC":"54629898360"},{"Id":404558,"FormularyType":"OHP","DrugName":"PRENATAL CAP FORMULA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512018000115","GenericName":"*PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-0.8-235 MG***","NDC":"54629899260"},{"Id":404559,"FormularyType":"OHP","DrugName":"VITACHEW D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"54629916480"},{"Id":404560,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"54738000133"},{"Id":404561,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"54738000201"},{"Id":404562,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"54738000233"},{"Id":404563,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"54738000301"},{"Id":404564,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"54738000333"},{"Id":404565,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"54738000350"},{"Id":404566,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"54738000401"},{"Id":404567,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"54738000542"},{"Id":404568,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"54738002003"},{"Id":404569,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"54738002501"},{"Id":404570,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"54738002503"},{"Id":404571,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"54738003015"},{"Id":404572,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"54738003060"},{"Id":404573,"FormularyType":"OHP","DrugName":"PRENATAL VIT TAB MINERALS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"54738005001"},{"Id":404574,"FormularyType":"OHP","DrugName":"CHILDRENS CHW APAP","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"54738009230"},{"Id":404575,"FormularyType":"OHP","DrugName":"CHLORPHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"54738010301"},{"Id":404576,"FormularyType":"OHP","DrugName":"CHLORPHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"54738010303"},{"Id":404577,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"54738011101"},{"Id":404578,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"54738011103"},{"Id":404579,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"54738011501"},{"Id":404580,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"54738011503"},{"Id":404581,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"54738011601"},{"Id":404582,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"54738011603"},{"Id":404583,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"54738012836"},{"Id":404584,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"54738012890"},{"Id":404585,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"54738014001"},{"Id":404586,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"54738054001"},{"Id":404587,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"54738054003"},{"Id":404588,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"54738054101"},{"Id":404589,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"54738054102"},{"Id":404590,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"54738054801"},{"Id":404591,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"54738054803"},{"Id":404592,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"54738054850"},{"Id":404593,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"54738055903"},{"Id":404594,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"54738055912"},{"Id":404595,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"54738055925"},{"Id":404596,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"54738096301"},{"Id":404597,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"54738096303"},{"Id":404598,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"54738097312"},{"Id":404599,"FormularyType":"OHP","DrugName":"SWEET CHEEKS GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"54758006289"},{"Id":404600,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"54838000180"},{"Id":404601,"FormularyType":"OHP","DrugName":"VITAMIN D3 DRO 10MCG/ML","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"54838000650"},{"Id":404602,"FormularyType":"OHP","DrugName":"FERROUS SULF DRO 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"54838001150"},{"Id":404603,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL SYP 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"54838050280"},{"Id":404604,"FormularyType":"OHP","DrugName":"OXYBUTYNIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045202010","GenericName":"OXYBUTYNIN CHLORIDE SOLUTION 5 MG/5ML","NDC":"54838051080"},{"Id":404605,"FormularyType":"OHP","DrugName":"ACETAMINOPHE LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"54859080916"},{"Id":404606,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 44MG/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"54859081016"},{"Id":404607,"FormularyType":"OHP","DrugName":"LIQUID ALLER LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"54859081116"},{"Id":404608,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100305","GenericName":"ETHAMBUTOL HCL TAB 100 MG","NDC":"54879000101"},{"Id":404609,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100310","GenericName":"ETHAMBUTOL HCL TAB 400 MG","NDC":"54879000201"},{"Id":404610,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"54932050181"},{"Id":404611,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"55111011230"},{"Id":404612,"FormularyType":"OHP","DrugName":"ZENATANE CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"55111011379"},{"Id":404613,"FormularyType":"OHP","DrugName":"ZENATANE CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"55111011381"},{"Id":404614,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"55111011890"},{"Id":404615,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"55111011901"},{"Id":404616,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"55111011910"},{"Id":404617,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"55111011930"},{"Id":404618,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"55111012001"},{"Id":404619,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"55111012010"},{"Id":404620,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"55111012030"},{"Id":404621,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"55111012105"},{"Id":404622,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"55111012190"},{"Id":404623,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"55111012205"},{"Id":404624,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"55111012290"},{"Id":404625,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"55111012305"},{"Id":404626,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"55111012390"},{"Id":404627,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"55111012405"},{"Id":404628,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"55111012490"},{"Id":404629,"FormularyType":"OHP","DrugName":"ENALAPR/HCTZ TAB 5-12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802350305","GenericName":"ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG","NDC":"55111013301"},{"Id":404630,"FormularyType":"OHP","DrugName":"ZENATANE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"55111013579"},{"Id":404631,"FormularyType":"OHP","DrugName":"ZENATANE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"55111013581"},{"Id":404632,"FormularyType":"OHP","DrugName":"ZENATANE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"55111013679"},{"Id":404633,"FormularyType":"OHP","DrugName":"ZENATANE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"55111013681"},{"Id":404634,"FormularyType":"OHP","DrugName":"ZENATANE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"55111013779"},{"Id":404635,"FormularyType":"OHP","DrugName":"ZENATANE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"55111013781"},{"Id":404636,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"55111014301"},{"Id":404637,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"55111014330"},{"Id":404638,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"55111014401"},{"Id":404639,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"55111014430"},{"Id":404640,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"55111014512"},{"Id":404641,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"55111014571"},{"Id":404642,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"55111014601"},{"Id":404643,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"55111014630"},{"Id":404644,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"55111015330"},{"Id":404645,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"55111015413"},{"Id":404646,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"55111015430"},{"Id":404647,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 24MG","DosageForm":"TABS - Tablet","Strength":"24","BrandVsGeneric":"N","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050340","GenericName":"ONDANSETRON HCL TAB 24 MG","NDC":"55111015611"},{"Id":404648,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"55111015701"},{"Id":404649,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"55111015730"},{"Id":404650,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111015801"},{"Id":404651,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111015810"},{"Id":404652,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111015830"},{"Id":404653,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111015834"},{"Id":404654,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111015901"},{"Id":404655,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111015905"},{"Id":404656,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111015910"},{"Id":404657,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111015930"},{"Id":404658,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"55111017205"},{"Id":404659,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"55111017290"},{"Id":404660,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"55111017910"},{"Id":404661,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"55111017915"},{"Id":404662,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"55111018010"},{"Id":404663,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"55111018015"},{"Id":404664,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"55111019630"},{"Id":404665,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"55111019690"},{"Id":404666,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"55111022905"},{"Id":404667,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"55111022990"},{"Id":404668,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"55111023005"},{"Id":404669,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"55111023090"},{"Id":404670,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"55111023105"},{"Id":404671,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"55111023190"},{"Id":404672,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"55111023301"},{"Id":404673,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"55111023401"},{"Id":404674,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"55111025205"},{"Id":404675,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"55111025505"},{"Id":404676,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"55111027405"},{"Id":404677,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"55111027490"},{"Id":404678,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"55111027950"},{"Id":404679,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"55111028050"},{"Id":404680,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"55111028130"},{"Id":404681,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"55111029109"},{"Id":404682,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"55111029136"},{"Id":404683,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"55111029190"},{"Id":404684,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"55111029198"},{"Id":404685,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"55111029209"},{"Id":404686,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"55111029236"},{"Id":404687,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"55111029290"},{"Id":404688,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"55111029298"},{"Id":404689,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"55111029309"},{"Id":404690,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"55111029336"},{"Id":404691,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"55111029390"},{"Id":404692,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"55111029398"},{"Id":404693,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"55111032001"},{"Id":404694,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"55111032005"},{"Id":404695,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"55111032101"},{"Id":404696,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"55111032105"},{"Id":404697,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"55111032201"},{"Id":404698,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"55111032205"},{"Id":404699,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"55111032890"},{"Id":404700,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"55111032990"},{"Id":404701,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"55111033290"},{"Id":404702,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"55111033390"},{"Id":404703,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 2.5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200120","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","NDC":"55111033801"},{"Id":404704,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"55111033901"},{"Id":404705,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"55111033905"},{"Id":404706,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"55111034001"},{"Id":404707,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"55111034005"},{"Id":404708,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"55111034101"},{"Id":404709,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"55111034105"},{"Id":404710,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"55111035205"},{"Id":404711,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"55111035260"},{"Id":404712,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"55111035305"},{"Id":404713,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"55111035360"},{"Id":404714,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"55111035405"},{"Id":404715,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"55111035460"},{"Id":404716,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"55111035505"},{"Id":404717,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"55111035560"},{"Id":404718,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"55111035605"},{"Id":404719,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"55111035610"},{"Id":404720,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"55111035630"},{"Id":404721,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"55111035690"},{"Id":404722,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"55111035705"},{"Id":404723,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"55111035710"},{"Id":404724,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"55111035730"},{"Id":404725,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"55111035790"},{"Id":404726,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"55111039601"},{"Id":404727,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"55111039830"},{"Id":404728,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"55111039890"},{"Id":404729,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"55111039905"},{"Id":404730,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"55111039930"},{"Id":404731,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"55111039990"},{"Id":404732,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100320","GenericName":"GALANTAMINE HYDROBROMIDE TAB 4 MG","NDC":"55111040760"},{"Id":404733,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100330","GenericName":"GALANTAMINE HYDROBROMIDE TAB 8 MG","NDC":"55111040860"},{"Id":404734,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100340","GenericName":"GALANTAMINE HYDROBROMIDE TAB 12 MG","NDC":"55111040960"},{"Id":404735,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"55111046601"},{"Id":404736,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"55111046605"},{"Id":404737,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"55111046701"},{"Id":404738,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"55111046705"},{"Id":404739,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"55111046801"},{"Id":404740,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"55111046805"},{"Id":404741,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"55111046901"},{"Id":404742,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"55111046905"},{"Id":404743,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"55111049660"},{"Id":404744,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"55111049704"},{"Id":404745,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"55111052501"},{"Id":404746,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"55111052601"},{"Id":404747,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"55111052701"},{"Id":404748,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"55111057503"},{"Id":404749,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"55111057511"},{"Id":404750,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"55111057543"},{"Id":404751,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"55111058601"},{"Id":404752,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200145","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","NDC":"55111058701"},{"Id":404753,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"55111058801"},{"Id":404754,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"55111058830"},{"Id":404755,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"55111059048"},{"Id":404756,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"55111059248"},{"Id":404757,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"55111059330"},{"Id":404758,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"55111059390"},{"Id":404759,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"55111059430"},{"Id":404760,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"55111059660"},{"Id":404761,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"55111059705"},{"Id":404762,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"55111059760"},{"Id":404763,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"55111061701"},{"Id":404764,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"55111061901"},{"Id":404765,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000310","GenericName":"ZAFIRLUKAST TAB 10 MG","NDC":"55111062560"},{"Id":404766,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000320","GenericName":"ZAFIRLUKAST TAB 20 MG","NDC":"55111062660"},{"Id":404767,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"55111062930"},{"Id":404768,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"55111064301"},{"Id":404769,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"55111064330"},{"Id":404770,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111064401"},{"Id":404771,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111064410"},{"Id":404772,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"55111064430"},{"Id":404773,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111064501"},{"Id":404774,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111064505"},{"Id":404775,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111064510"},{"Id":404776,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111064530"},{"Id":404777,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"55111064534"},{"Id":404778,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"55111065301"},{"Id":404779,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000330","GenericName":"SIROLIMUS TAB 2 MG","NDC":"55111065401"},{"Id":404780,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 1 MCG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000110","GenericName":"PARICALCITOL CAP 1 MCG","NDC":"55111066330"},{"Id":404781,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 2 MCG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000120","GenericName":"PARICALCITOL CAP 2 MCG","NDC":"55111066430"},{"Id":404782,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"55111067802"},{"Id":404783,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"55111067810"},{"Id":404784,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"55111067902"},{"Id":404785,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"55111067910"},{"Id":404786,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"55111068002"},{"Id":404787,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"55111068010"},{"Id":404788,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"55111068102"},{"Id":404789,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"55111068110"},{"Id":404790,"FormularyType":"OHP","DrugName":"IBU TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"55111068201"},{"Id":404791,"FormularyType":"OHP","DrugName":"IBU TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"55111068205"},{"Id":404792,"FormularyType":"OHP","DrugName":"IBU TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"55111068209"},{"Id":404793,"FormularyType":"OHP","DrugName":"IBU TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"55111068299"},{"Id":404794,"FormularyType":"OHP","DrugName":"IBU TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"55111068301"},{"Id":404795,"FormularyType":"OHP","DrugName":"IBU TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"55111068305"},{"Id":404796,"FormularyType":"OHP","DrugName":"IBU TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"55111068330"},{"Id":404797,"FormularyType":"OHP","DrugName":"IBU TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"55111068350"},{"Id":404798,"FormularyType":"OHP","DrugName":"IBU TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"55111068388"},{"Id":404799,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068401"},{"Id":404800,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068405"},{"Id":404801,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068409"},{"Id":404802,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068430"},{"Id":404803,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068450"},{"Id":404804,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068460"},{"Id":404805,"FormularyType":"OHP","DrugName":"IBU TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"55111068469"},{"Id":404806,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"55111069305"},{"Id":404807,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"55111069312"},{"Id":404808,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"55111069990"},{"Id":404809,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"55111072510"},{"Id":404810,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"55111072530"},{"Id":404811,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"55111072590"},{"Id":404812,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"55111072594"},{"Id":404813,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"55111072901"},{"Id":404814,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"55111072910"},{"Id":404815,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"55111073001"},{"Id":404816,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"55111073005"},{"Id":404817,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"55111073130"},{"Id":404818,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"55111073190"},{"Id":404819,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"55111073290"},{"Id":404820,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"55111073390"},{"Id":404821,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"55111073490"},{"Id":404822,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"55111076260"},{"Id":404823,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"55111076303"},{"Id":404824,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"55111076307"},{"Id":404825,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"55111078301"},{"Id":404826,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"55111078401"},{"Id":404827,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"55111078430"},{"Id":404828,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"55111078911"},{"Id":404829,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"55111078927"},{"Id":404830,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"55111078948"},{"Id":404831,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"55111079630"},{"Id":404832,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"55111079730"},{"Id":404833,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302110","GenericName":"AMPICILLIN SODIUM FOR INJ 250 MG","NDC":"55150011110"},{"Id":404834,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"55150011210"},{"Id":404835,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"55150011310"},{"Id":404836,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"55150011420"},{"Id":404837,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"55150011599"},{"Id":404838,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"55150011601"},{"Id":404839,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"55150011610"},{"Id":404840,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"55150011620"},{"Id":404841,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"55150011701"},{"Id":404842,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"55150011710"},{"Id":404843,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"55150011720"},{"Id":404844,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"55150011801"},{"Id":404845,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"55150011899"},{"Id":404846,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"55150011930"},{"Id":404847,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"55150012030"},{"Id":404848,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"55150012150"},{"Id":404849,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102105","GenericName":"NAFCILLIN SODIUM FOR INJ 1 GM","NDC":"55150012215"},{"Id":404850,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"55150012315"},{"Id":404851,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"55150012316"},{"Id":404852,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"55150012409"},{"Id":404853,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"55150012499"},{"Id":404854,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102115","GenericName":"OXACILLIN SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"55150012715"},{"Id":404855,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102120","GenericName":"OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT)","NDC":"55150012824"},{"Id":404856,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102131","GenericName":"OXACILLIN SODIUM FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"55150012999"},{"Id":404857,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"N","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002020","GenericName":"LEVOFLOXACIN IV SOLN 25 MG/ML","NDC":"55150015620"},{"Id":404858,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"55150017301"},{"Id":404859,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"55150017305"},{"Id":404860,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"55150017410"},{"Id":404861,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"55150018703"},{"Id":404862,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"55150020420"},{"Id":404863,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"55150020720"},{"Id":404864,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"55150020830"},{"Id":404865,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"55150023000"},{"Id":404866,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"55150023010"},{"Id":404867,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"55150023100"},{"Id":404868,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"55150023110"},{"Id":404869,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"55150023200"},{"Id":404870,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"55150023210"},{"Id":404871,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"55150023300"},{"Id":404872,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"55150023310"},{"Id":404873,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"55150024251"},{"Id":404874,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"55150024346"},{"Id":404875,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"55150024447"},{"Id":404876,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"55150024552"},{"Id":404877,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102010","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML","NDC":"55150027601"},{"Id":404878,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"55150027701"},{"Id":404879,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"55150027801"},{"Id":404880,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"55150028209"},{"Id":404881,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"55150028220"},{"Id":404882,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"55150032201"},{"Id":404883,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"55150032225"},{"Id":404884,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"55150032301"},{"Id":404885,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"55150032325"},{"Id":404886,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"55150032401"},{"Id":404887,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"55150032425"},{"Id":404888,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"55150032701"},{"Id":404889,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"55150032710"},{"Id":404890,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"55150032901"},{"Id":404891,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"55150032925"},{"Id":404892,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2515003510E620","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML","NDC":"55150033001"},{"Id":404893,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"55150034201"},{"Id":404894,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"55150034225"},{"Id":404895,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"55150034301"},{"Id":404896,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"55150034305"},{"Id":404897,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"55150034501"},{"Id":404898,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"55150034510"},{"Id":404899,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"55150035101"},{"Id":404900,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"55150035103"},{"Id":404901,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"55150036425"},{"Id":404902,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 200/5ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"55150038401"},{"Id":404903,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 400/10ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"55150038501"},{"Id":404904,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"55150040201"},{"Id":404905,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"55150040225"},{"Id":404906,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"55150040301"},{"Id":404907,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"55150040325"},{"Id":404908,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"55150047101"},{"Id":404909,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"55150047110"},{"Id":404910,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"55150047201"},{"Id":404911,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"55150047210"},{"Id":404912,"FormularyType":"OHP","DrugName":"LEUPROLIDE KIT 14 DAY","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"55150047801"},{"Id":404913,"FormularyType":"OHP","DrugName":"SIGNIFOR INJ 0.3MG/ML","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170075202020","GenericName":"PASIREOTIDE DIASPARTATE INJ 0.3 MG/ML (BASE EQUIV)","NDC":"55292013160"},{"Id":404914,"FormularyType":"OHP","DrugName":"SIGNIFOR INJ 0.6MG/ML","DosageForm":"SOLN - Solution","Strength":"0.6","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170075202030","GenericName":"PASIREOTIDE DIASPARTATE INJ 0.6 MG/ML (BASE EQUIV)","NDC":"55292013260"},{"Id":404915,"FormularyType":"OHP","DrugName":"SIGNIFOR INJ 0.9MG/ML","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170075202040","GenericName":"PASIREOTIDE DIASPARTATE INJ 0.9 MG/ML (BASE EQUIV)","NDC":"55292013360"},{"Id":404916,"FormularyType":"OHP","DrugName":"TITRALAC CHW 420MG","DosageForm":"CHEW - Tablet Chewable","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000505","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 420 MG","NDC":"55298003810"},{"Id":404917,"FormularyType":"OHP","DrugName":"LEVO-T TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"55466010411"},{"Id":404918,"FormularyType":"OHP","DrugName":"LEVO-T TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"55466010419"},{"Id":404919,"FormularyType":"OHP","DrugName":"LEVO-T TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"55466010511"},{"Id":404920,"FormularyType":"OHP","DrugName":"LEVO-T TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"55466010519"},{"Id":404921,"FormularyType":"OHP","DrugName":"LEVO-T TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"55466010611"},{"Id":404922,"FormularyType":"OHP","DrugName":"LEVO-T TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"55466010619"},{"Id":404923,"FormularyType":"OHP","DrugName":"LEVO-T TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"55466010711"},{"Id":404924,"FormularyType":"OHP","DrugName":"LEVO-T TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"55466010811"},{"Id":404925,"FormularyType":"OHP","DrugName":"LEVO-T TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"55466010819"},{"Id":404926,"FormularyType":"OHP","DrugName":"LEVO-T TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"55466010911"},{"Id":404927,"FormularyType":"OHP","DrugName":"LEVO-T TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"55466011011"},{"Id":404928,"FormularyType":"OHP","DrugName":"LEVO-T TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"55466011019"},{"Id":404929,"FormularyType":"OHP","DrugName":"LEVO-T TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"55466011111"},{"Id":404930,"FormularyType":"OHP","DrugName":"LEVO-T TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"55466011211"},{"Id":404931,"FormularyType":"OHP","DrugName":"LEVO-T TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"55466011311"},{"Id":404932,"FormularyType":"OHP","DrugName":"LEVO-T TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"55466011411"},{"Id":404933,"FormularyType":"OHP","DrugName":"LEVO-T TAB 300 MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"55466011511"},{"Id":404934,"FormularyType":"OHP","DrugName":"ARANESP INJ 25MCG","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102010","GenericName":"DARBEPOETIN ALFA SOLN INJ 25 MCG/ML","NDC":"55513000201"},{"Id":404935,"FormularyType":"OHP","DrugName":"ARANESP INJ 25MCG","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102010","GenericName":"DARBEPOETIN ALFA SOLN INJ 25 MCG/ML","NDC":"55513000204"},{"Id":404936,"FormularyType":"OHP","DrugName":"ARANESP INJ 40MCG","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102020","GenericName":"DARBEPOETIN ALFA SOLN INJ 40 MCG/ML","NDC":"55513000301"},{"Id":404937,"FormularyType":"OHP","DrugName":"ARANESP INJ 40MCG","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102020","GenericName":"DARBEPOETIN ALFA SOLN INJ 40 MCG/ML","NDC":"55513000304"},{"Id":404938,"FormularyType":"OHP","DrugName":"ARANESP INJ 60MCG","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102030","GenericName":"DARBEPOETIN ALFA SOLN INJ 60 MCG/ML","NDC":"55513000401"},{"Id":404939,"FormularyType":"OHP","DrugName":"ARANESP INJ 60MCG","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102030","GenericName":"DARBEPOETIN ALFA SOLN INJ 60 MCG/ML","NDC":"55513000404"},{"Id":404940,"FormularyType":"OHP","DrugName":"ARANESP INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102040","GenericName":"DARBEPOETIN ALFA SOLN INJ 100 MCG/ML","NDC":"55513000501"},{"Id":404941,"FormularyType":"OHP","DrugName":"ARANESP INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102040","GenericName":"DARBEPOETIN ALFA SOLN INJ 100 MCG/ML","NDC":"55513000504"},{"Id":404942,"FormularyType":"OHP","DrugName":"ARANESP INJ 200MCG","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401015102060","GenericName":"DARBEPOETIN ALFA SOLN INJ 200 MCG/ML","NDC":"55513000601"},{"Id":404943,"FormularyType":"OHP","DrugName":"ARANESP INJ 40MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E543","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 40 MCG/0.4ML","NDC":"55513002101"},{"Id":404944,"FormularyType":"OHP","DrugName":"ARANESP INJ 40MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E543","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 40 MCG/0.4ML","NDC":"55513002104"},{"Id":404945,"FormularyType":"OHP","DrugName":"ARANESP INJ 60MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E552","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 60 MCG/0.3ML","NDC":"55513002301"},{"Id":404946,"FormularyType":"OHP","DrugName":"ARANESP INJ 60MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E552","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 60 MCG/0.3ML","NDC":"55513002304"},{"Id":404947,"FormularyType":"OHP","DrugName":"ARANESP INJ 100MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E560","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 100 MCG/0.5ML","NDC":"55513002501"},{"Id":404948,"FormularyType":"OHP","DrugName":"ARANESP INJ 100MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E560","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 100 MCG/0.5ML","NDC":"55513002504"},{"Id":404949,"FormularyType":"OHP","DrugName":"ARANESP INJ 150MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E575","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 150 MCG/0.3ML","NDC":"55513002701"},{"Id":404950,"FormularyType":"OHP","DrugName":"ARANESP INJ 150MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E575","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 150 MCG/0.3ML","NDC":"55513002704"},{"Id":404951,"FormularyType":"OHP","DrugName":"ARANESP INJ 200MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"200","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E582","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 200 MCG/0.4ML","NDC":"55513002801"},{"Id":404952,"FormularyType":"OHP","DrugName":"ARANESP INJ 500MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"500","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E590","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 500 MCG/ML","NDC":"55513003201"},{"Id":404953,"FormularyType":"OHP","DrugName":"ARANESP INJ 25MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E528","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 25 MCG/0.42ML","NDC":"55513005701"},{"Id":404954,"FormularyType":"OHP","DrugName":"ARANESP INJ 25MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E528","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 25 MCG/0.42ML","NDC":"55513005704"},{"Id":404955,"FormularyType":"OHP","DrugName":"ARANESP INJ 10MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E510","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 10 MCG/0.4ML","NDC":"55513009801"},{"Id":404956,"FormularyType":"OHP","DrugName":"ARANESP INJ 10MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E510","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 10 MCG/0.4ML","NDC":"55513009804"},{"Id":404957,"FormularyType":"OHP","DrugName":"ARANESP INJ 300MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240101510E588","GenericName":"DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 300 MCG/0.6ML","NDC":"55513011101"},{"Id":404958,"FormularyType":"OHP","DrugName":"OTEZLA TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66700015000330","GenericName":"APREMILAST TAB 30 MG","NDC":"55513013760"},{"Id":404959,"FormularyType":"OHP","DrugName":"OTEZLA TAB 10/20/30","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6670001500B720","GenericName":"APREMILAST TAB STARTER THERAPY PACK 10 MG & 20 MG & 30 MG","NDC":"55513036955"},{"Id":404960,"FormularyType":"OHP","DrugName":"LUMAKRAS TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532480000320","GenericName":"SOTORASIB TAB 120 MG","NDC":"55513048824"},{"Id":404961,"FormularyType":"OHP","DrugName":"LUMAKRAS TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532480000320","GenericName":"SOTORASIB TAB 120 MG","NDC":"55513048840"},{"Id":404962,"FormularyType":"OHP","DrugName":"OTEZLA TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66700015000320","GenericName":"APREMILAST TAB 20 MG","NDC":"55513049760"},{"Id":404963,"FormularyType":"OHP","DrugName":"LUMAKRAS TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532480000340","GenericName":"SOTORASIB TAB 320 MG","NDC":"55513050450"},{"Id":404964,"FormularyType":"OHP","DrugName":"OTEZLA TAB 10/20","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6670001500B710","GenericName":"APREMILAST TAB STARTER THERAPY PACK 4 X 10 MG & 51 X 20 MG","NDC":"55513050855"},{"Id":404965,"FormularyType":"OHP","DrugName":"LUMAKRAS TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532480000330","GenericName":"SOTORASIB TAB 240 MG","NDC":"55513051260"},{"Id":404966,"FormularyType":"OHP","DrugName":"OTEZLA/XR TAB 28 DAY","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6670001500B740","GenericName":"APREMILAST TAB START PACK 10 MG & 20 MG & 30 MG & (ER) 75 MG","NDC":"55513051641"},{"Id":404967,"FormularyType":"OHP","DrugName":"OTEZLA XR TAB 75MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66700015007530","GenericName":"APREMILAST TAB ER 24HR 75 MG","NDC":"55513051930"},{"Id":404968,"FormularyType":"OHP","DrugName":"CORLANOR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035102020","GenericName":"IVABRADINE HCL ORAL SOLN 5 MG/5ML (BASE EQUIV)","NDC":"55513081301"},{"Id":404969,"FormularyType":"OHP","DrugName":"CORLANOR SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035102020","GenericName":"IVABRADINE HCL ORAL SOLN 5 MG/5ML (BASE EQUIV)","NDC":"55513081328"},{"Id":404970,"FormularyType":"OHP","DrugName":"AIMOVIG INJ 70MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770202010D520","GenericName":"ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 70 MG/ML","NDC":"55513084101"},{"Id":404971,"FormularyType":"OHP","DrugName":"AIMOVIG INJ 140MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"140","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770202010D540","GenericName":"ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","NDC":"55513084300"},{"Id":404972,"FormularyType":"OHP","DrugName":"AIMOVIG INJ 140MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"140","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6770202010D540","GenericName":"ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","NDC":"55513084301"},{"Id":404973,"FormularyType":"OHP","DrugName":"ZOMACTON INJ 5MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30100020002121","GenericName":"SOMATROPIN FOR SUBCUTANEOUS INJ 5 MG","NDC":"55566180101"},{"Id":404974,"FormularyType":"OHP","DrugName":"ZOMACTON INJ 10MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"GROWTH HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30100020002140","GenericName":"SOMATROPIN FOR INJ 10 MG","NDC":"55566190101"},{"Id":404975,"FormularyType":"OHP","DrugName":"ANTIGEN TEST KIT 2-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"55636000372"},{"Id":404976,"FormularyType":"OHP","DrugName":"ANTIGEN TEST KIT 8-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"55636000375"},{"Id":404977,"FormularyType":"OHP","DrugName":"EUCRISA OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230025004220","GenericName":"CRISABOROLE OINT 2%","NDC":"55724021111"},{"Id":404978,"FormularyType":"OHP","DrugName":"EUCRISA OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230025004220","GenericName":"CRISABOROLE OINT 2%","NDC":"55724021121"},{"Id":404979,"FormularyType":"OHP","DrugName":"EUCRISA OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230025004220","GenericName":"CRISABOROLE OINT 2%","NDC":"55724021123"},{"Id":404980,"FormularyType":"OHP","DrugName":"HABITROL DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"55741044870"},{"Id":404981,"FormularyType":"OHP","DrugName":"HABITROL DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"55741044874"},{"Id":404982,"FormularyType":"OHP","DrugName":"YUMVS GLUCOS CHW 2GM","DosageForm":"CHEW - Tablet Chewable","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000509","GenericName":"GLUCOSE CHEW TAB 2 GM (CARB EQUIV)","NDC":"56023000714"},{"Id":404983,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL ORANGE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000600"},{"Id":404984,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000601"},{"Id":404985,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL LEMONADE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000602"},{"Id":404986,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL ORANGE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000608"},{"Id":404987,"FormularyType":"OHP","DrugName":"HYDRALATE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000609"},{"Id":404988,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL LEMONADE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000610"},{"Id":404989,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL ORANGE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000618"},{"Id":404990,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL ORANGE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000623"},{"Id":404991,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000624"},{"Id":404992,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000631"},{"Id":404993,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL LEMONADE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000636"},{"Id":404994,"FormularyType":"OHP","DrugName":"HYDRALYTE SOL ORANGE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"56069000675"},{"Id":404995,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 26G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151014101"},{"Id":404996,"FormularyType":"OHP","DrugName":"TRUEDRAW MIS LANC DEV","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202027006300","GenericName":"*LANCET DEVICES***","NDC":"56151014201"},{"Id":404997,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151014260"},{"Id":404998,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151014401"},{"Id":404999,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151014402"},{"Id":405000,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 33G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151014701"},{"Id":405001,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151014801"},{"Id":405002,"FormularyType":"OHP","DrugName":"LANCETS MIS 28G THIN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151024221"},{"Id":405003,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151034001"},{"Id":405004,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151034002"},{"Id":405005,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151034101"},{"Id":405006,"FormularyType":"OHP","DrugName":"TRUPLUS LANC MIS 28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"56151034125"},{"Id":405007,"FormularyType":"OHP","DrugName":"TRUE METRIX SOL LEVEL 1","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100930","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID - LOW***","NDC":"56151145001"},{"Id":405008,"FormularyType":"OHP","DrugName":"TRUE METRIX SOL LEVEL 2","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100920","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID - NORMAL***","NDC":"56151145002"},{"Id":405009,"FormularyType":"OHP","DrugName":"TRUE METRIX SOL LEVEL 3","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100910","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID - HIGH***","NDC":"56151145003"},{"Id":405010,"FormularyType":"OHP","DrugName":"TRUE METRIX TES GLUCOSE","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"56151146001"},{"Id":405011,"FormularyType":"OHP","DrugName":"TRUE METRIX TES GLUCOSE","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"56151146004"},{"Id":405012,"FormularyType":"OHP","DrugName":"RELION TRUE TES METRIX","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"56151146101"},{"Id":405013,"FormularyType":"OHP","DrugName":"RELION TRUE TES METRIX","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"56151146104"},{"Id":405014,"FormularyType":"OHP","DrugName":"TRUE METRIX TES GLUCOSE","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"56151146304"},{"Id":405015,"FormularyType":"OHP","DrugName":"TRUE METRIX KIT AIR","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202010006410","GenericName":"*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","NDC":"56151149002"},{"Id":405016,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUC ORG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"56151161011"},{"Id":405017,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUCOSE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"56151161051"},{"Id":405018,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLU RASP","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"56151161111"},{"Id":405019,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUCOSE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"56151161151"},{"Id":405020,"FormularyType":"OHP","DrugName":"TRUEPLUS CHW GLUCOSE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"56151161351"},{"Id":405021,"FormularyType":"OHP","DrugName":"TRUEPLS GLUC GEL 15/32ML","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004040","GenericName":"GLUCOSE GEL 15 GM/32ML","NDC":"56151162501"},{"Id":405022,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"56151170201"},{"Id":405023,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"56151170301"},{"Id":405024,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"56151171101"},{"Id":405025,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"56151171201"},{"Id":405026,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"56151171301"},{"Id":405027,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"56151172101"},{"Id":405028,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"56151172201"},{"Id":405029,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"56151172301"},{"Id":405030,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"56151173101"},{"Id":405031,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"56151173201"},{"Id":405032,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"56151173301"},{"Id":405033,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"56151211001"},{"Id":405034,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"56151211101"},{"Id":405035,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"56151211201"},{"Id":405036,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"56151211301"},{"Id":405037,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"56151211401"},{"Id":405038,"FormularyType":"OHP","DrugName":"DIATHRIVE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"56153000805"},{"Id":405039,"FormularyType":"OHP","DrugName":"DIATHRIVE MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"56153000821"},{"Id":405040,"FormularyType":"OHP","DrugName":"DIATHRIVE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"56153000822"},{"Id":405041,"FormularyType":"OHP","DrugName":"DIATHRIVE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"56153000823"},{"Id":405042,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"56156000306"},{"Id":405043,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"56156000307"},{"Id":405044,"FormularyType":"OHP","DrugName":"LITTLE REMED LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"56184010124"},{"Id":405045,"FormularyType":"OHP","DrugName":"LITTLE REMED LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"56184010176"},{"Id":405046,"FormularyType":"OHP","DrugName":"LITTLE REMED LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"56184010177"},{"Id":405047,"FormularyType":"OHP","DrugName":"LITTLE REMED LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"56184010178"},{"Id":405048,"FormularyType":"OHP","DrugName":"LITTLE REMED LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"56184010653"},{"Id":405049,"FormularyType":"OHP","DrugName":"IHEALTH 2-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"56362000589"},{"Id":405050,"FormularyType":"OHP","DrugName":"IHEALTH 5-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"56362000590"},{"Id":405051,"FormularyType":"OHP","DrugName":"IHEALTH 40PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"56362000596"},{"Id":405052,"FormularyType":"OHP","DrugName":"NOZIN NASAL MIS SANITIZE","DosageForm":"SWAB - Swab","Strength":"62","BrandVsGeneric":"N","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42500005009400","GenericName":"*ALCOHOL NASAL SWABS***","NDC":"56923000121"},{"Id":405053,"FormularyType":"OHP","DrugName":"NOZIN NASAL MIS SANITIZE","DosageForm":"SWAB - Swab","Strength":"62","BrandVsGeneric":"N","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42500005009400","GenericName":"*ALCOHOL NASAL SWABS***","NDC":"56923001153"},{"Id":405054,"FormularyType":"OHP","DrugName":"NOZIN NASAL MIS SANITIZE","DosageForm":"SWAB - Swab","Strength":"62","BrandVsGeneric":"N","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42500005009400","GenericName":"*ALCOHOL NASAL SWABS***","NDC":"56923001160"},{"Id":405055,"FormularyType":"OHP","DrugName":"NOZIN NASAL MIS SANITIZE","DosageForm":"SWAB - Swab","Strength":"62","BrandVsGeneric":"N","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42500005009400","GenericName":"*ALCOHOL NASAL SWABS***","NDC":"56923001164"},{"Id":405056,"FormularyType":"OHP","DrugName":"ELLUME COV19 KIT HOME TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"56964000000"},{"Id":405057,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"57237000201"},{"Id":405058,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"57237000205"},{"Id":405059,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"57237000299"},{"Id":405060,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"57237000330"},{"Id":405061,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"57237000430"},{"Id":405062,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"57237000511"},{"Id":405063,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"57237000601"},{"Id":405064,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"57237000630"},{"Id":405065,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"57237001401"},{"Id":405066,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"57237001405"},{"Id":405067,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 1.25-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400310","GenericName":"GLYBURIDE-METFORMIN TAB 1.25-250 MG","NDC":"57237002301"},{"Id":405068,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 1.25-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400310","GenericName":"GLYBURIDE-METFORMIN TAB 1.25-250 MG","NDC":"57237002305"},{"Id":405069,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400320","GenericName":"GLYBURIDE-METFORMIN TAB 2.5-500 MG","NDC":"57237002401"},{"Id":405070,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400320","GenericName":"GLYBURIDE-METFORMIN TAB 2.5-500 MG","NDC":"57237002405"},{"Id":405071,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400330","GenericName":"GLYBURIDE-METFORMIN TAB 5-500 MG","NDC":"57237002501"},{"Id":405072,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400330","GenericName":"GLYBURIDE-METFORMIN TAB 5-500 MG","NDC":"57237002505"},{"Id":405073,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100303","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 500 MG","NDC":"57237002801"},{"Id":405074,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"57237002901"},{"Id":405075,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"57237002920"},{"Id":405076,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"57237003001"},{"Id":405077,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"57237003005"},{"Id":405078,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"57237003101"},{"Id":405079,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"57237003105"},{"Id":405080,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"57237003201"},{"Id":405081,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"57237003250"},{"Id":405082,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"57237003275"},{"Id":405083,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"57237003301"},{"Id":405084,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"57237003350"},{"Id":405085,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"57237003375"},{"Id":405086,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"57237003401"},{"Id":405087,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"57237003450"},{"Id":405088,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"57237003475"},{"Id":405089,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"57237003501"},{"Id":405090,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"57237003550"},{"Id":405091,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"57237003575"},{"Id":405092,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"57237003601"},{"Id":405093,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"57237003750"},{"Id":405094,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"57237004001"},{"Id":405095,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"57237004099"},{"Id":405096,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"57237004101"},{"Id":405097,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"57237004105"},{"Id":405098,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"57237004199"},{"Id":405099,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"57237004230"},{"Id":405100,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"57237004290"},{"Id":405101,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"57237004330"},{"Id":405102,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"57237004390"},{"Id":405103,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000310","GenericName":"CLARITHROMYCIN TAB 250 MG","NDC":"57237004460"},{"Id":405104,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"57237004560"},{"Id":405105,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100320","GenericName":"GALANTAMINE HYDROBROMIDE TAB 4 MG","NDC":"57237004960"},{"Id":405106,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100330","GenericName":"GALANTAMINE HYDROBROMIDE TAB 8 MG","NDC":"57237005060"},{"Id":405107,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100340","GenericName":"GALANTAMINE HYDROBROMIDE TAB 12 MG","NDC":"57237005160"},{"Id":405108,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"57237005820"},{"Id":405109,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"57237005860"},{"Id":405110,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"57237005920"},{"Id":405111,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"57237005960"},{"Id":405112,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"57237006130"},{"Id":405113,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"57237006190"},{"Id":405114,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"57237006205"},{"Id":405115,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"57237006230"},{"Id":405116,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"57237006290"},{"Id":405117,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"57237006301"},{"Id":405118,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"57237006401"},{"Id":405119,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"57237006501"},{"Id":405120,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"57237007530"},{"Id":405121,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"57237007550"},{"Id":405122,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"57237007630"},{"Id":405123,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"57237007650"},{"Id":405124,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"57237007710"},{"Id":405125,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"57237007730"},{"Id":405126,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"57237007750"},{"Id":405127,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"57237007810"},{"Id":405128,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"57237007830"},{"Id":405129,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"57237007850"},{"Id":405130,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"57237008563"},{"Id":405131,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"57237008663"},{"Id":405132,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57237008734"},{"Id":405133,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57237008763"},{"Id":405134,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57237008834"},{"Id":405135,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57237008863"},{"Id":405136,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"57237009601"},{"Id":405137,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"57237009650"},{"Id":405138,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001910","GenericName":"CEFADROXIL FOR SUSP 250 MG/5ML","NDC":"57237009701"},{"Id":405139,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"57237009801"},{"Id":405140,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"57237009875"},{"Id":405141,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"57237009960"},{"Id":405142,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"57237010001"},{"Id":405143,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"57237010099"},{"Id":405144,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"57237010101"},{"Id":405145,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"57237010199"},{"Id":405146,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"57237010201"},{"Id":405147,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"57237010299"},{"Id":405148,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"57237010801"},{"Id":405149,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"57237010901"},{"Id":405150,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"57237011001"},{"Id":405151,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"57237011490"},{"Id":405152,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"57237013801"},{"Id":405153,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"57237013901"},{"Id":405154,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"57237014001"},{"Id":405155,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"57237014101"},{"Id":405156,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 2.5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200120","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","NDC":"57237014201"},{"Id":405157,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"57237014301"},{"Id":405158,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"57237014401"},{"Id":405159,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200145","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","NDC":"57237014501"},{"Id":405160,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"57237014601"},{"Id":405161,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"57237014701"},{"Id":405162,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 10MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001910","GenericName":"FLUCONAZOLE FOR SUSP 10 MG/ML","NDC":"57237014935"},{"Id":405163,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001940","GenericName":"FLUCONAZOLE FOR SUSP 40 MG/ML","NDC":"57237015035"},{"Id":405164,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"57237015630"},{"Id":405165,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"57237016001"},{"Id":405166,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"57237016030"},{"Id":405167,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"57237016130"},{"Id":405168,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"57237016190"},{"Id":405169,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"57237016199"},{"Id":405170,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"57237016201"},{"Id":405171,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"57237016230"},{"Id":405172,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"57237016250"},{"Id":405173,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"57237016290"},{"Id":405174,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"57237016805"},{"Id":405175,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"57237016890"},{"Id":405176,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"57237016990"},{"Id":405177,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"57237016999"},{"Id":405178,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"57237017090"},{"Id":405179,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"57237017099"},{"Id":405180,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"57237017105"},{"Id":405181,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"57237017130"},{"Id":405182,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"57237017190"},{"Id":405183,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"57237018090"},{"Id":405184,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"57237018190"},{"Id":405185,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"57237018290"},{"Id":405186,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"57237018390"},{"Id":405187,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"57237018490"},{"Id":405188,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"57237018590"},{"Id":405189,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"57237021230"},{"Id":405190,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"57237021290"},{"Id":405191,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"57237021330"},{"Id":405192,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"57237021390"},{"Id":405193,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400320","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","NDC":"57237021760"},{"Id":405194,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400320","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","NDC":"57237021781"},{"Id":405195,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-850MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400340","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","NDC":"57237021860"},{"Id":405196,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-850MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400340","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","NDC":"57237021881"},{"Id":405197,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"57237021905"},{"Id":405198,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"57237021930"},{"Id":405199,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"57237021990"},{"Id":405200,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"57237022005"},{"Id":405201,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"57237022030"},{"Id":405202,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"57237022090"},{"Id":405203,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"57237022105"},{"Id":405204,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"57237022130"},{"Id":405205,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"57237022190"},{"Id":405206,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"57237022201"},{"Id":405207,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"57237022230"},{"Id":405208,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"57237022301"},{"Id":405209,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"57237022305"},{"Id":405210,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"57237022401"},{"Id":405211,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"57237022405"},{"Id":405212,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"57237022501"},{"Id":405213,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"57237022505"},{"Id":405214,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"57237023201"},{"Id":405215,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"57237023205"},{"Id":405216,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"57237023301"},{"Id":405217,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"57237023305"},{"Id":405218,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000120","GenericName":"ZALEPLON CAP 5 MG","NDC":"57237023901"},{"Id":405219,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000130","GenericName":"ZALEPLON CAP 10 MG","NDC":"57237024001"},{"Id":405220,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"57237025530"},{"Id":405221,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"57237025590"},{"Id":405222,"FormularyType":"OHP","DrugName":"LAMIVUDINE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060002020","GenericName":"LAMIVUDINE ORAL SOLN 10 MG/ML","NDC":"57237027424"},{"Id":405223,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"57237030124"},{"Id":405224,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"57237030412"},{"Id":405225,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"57237030416"},{"Id":405226,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"57237030512"},{"Id":405227,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"57237030516"},{"Id":405228,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"57237031005"},{"Id":405229,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"57237031054"},{"Id":405230,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"57237031105"},{"Id":405231,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"57237031151"},{"Id":405232,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57237031431"},{"Id":405233,"FormularyType":"OHP","DrugName":"ALUM/MAGNES/ SUS SIMETH","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"57237031603"},{"Id":405234,"FormularyType":"OHP","DrugName":"ALUM/MAGNES/ SUS SIMETH","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"57237031631"},{"Id":405235,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"57237031751"},{"Id":405236,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"57237031811"},{"Id":405237,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"57237032072"},{"Id":405238,"FormularyType":"OHP","DrugName":"NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"57237032081"},{"Id":405239,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"57237032172"},{"Id":405240,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"57237032181"},{"Id":405241,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"57237032201"},{"Id":405242,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"57237032211"},{"Id":405243,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"57237032250"},{"Id":405244,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"57237032301"},{"Id":405245,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"57237032311"},{"Id":405246,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"57237032350"},{"Id":405247,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57237032703"},{"Id":405248,"FormularyType":"OHP","DrugName":"PROCTOZONE-B SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57237033703"},{"Id":405249,"FormularyType":"OHP","DrugName":"PROCTOZONE-B SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57237033704"},{"Id":405250,"FormularyType":"OHP","DrugName":"PROCTOZONE-B SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57237033721"},{"Id":405251,"FormularyType":"OHP","DrugName":"PROCTOZONE- SUP 1.2G","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"57237033821"},{"Id":405252,"FormularyType":"OHP","DrugName":"PROCTOZONE- SUP 1.2G","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"57237033852"},{"Id":405253,"FormularyType":"OHP","DrugName":"PROCTOZONE-G SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"57237033916"},{"Id":405254,"FormularyType":"OHP","DrugName":"PROCTOZONE-G SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"57237033921"},{"Id":405255,"FormularyType":"OHP","DrugName":"PROCTOZONE-G SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"57237033951"},{"Id":405256,"FormularyType":"OHP","DrugName":"PROCTOZONE-G SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"57237033952"},{"Id":405257,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"57237034601"},{"Id":405258,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"57237034610"},{"Id":405259,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57237034701"},{"Id":405260,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57237034705"},{"Id":405261,"FormularyType":"OHP","DrugName":"APAP/ASA/ TAB CAFFEINE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"57237034801"},{"Id":405262,"FormularyType":"OHP","DrugName":"ASPIRIN ADLT TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57237034910"},{"Id":405263,"FormularyType":"OHP","DrugName":"ASPIRIN ADLT TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57237034912"},{"Id":405264,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"57237036501"},{"Id":405265,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"57237036510"},{"Id":405266,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"57237036601"},{"Id":405267,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"57237036610"},{"Id":405268,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57273000209"},{"Id":405269,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"57273000221"},{"Id":405270,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX10MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146326","GenericName":"INSULIN PEN NEEDLE 29 G X 10 MM","NDC":"57273000222"},{"Id":405271,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57273000223"},{"Id":405272,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57273000224"},{"Id":405273,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57273000225"},{"Id":405274,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"57273000226"},{"Id":405275,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"57273000227"},{"Id":405276,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"57273000228"},{"Id":405277,"FormularyType":"OHP","DrugName":"DROPLET MICR MIS 34GX9/64","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146385","GenericName":"INSULIN PEN NEEDLE 34 G X 3.5 MM (9/64\")","NDC":"57273000230"},{"Id":405278,"FormularyType":"OHP","DrugName":"DROPSAFE MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"57273000256"},{"Id":405279,"FormularyType":"OHP","DrugName":"DROPSAFE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57273000257"},{"Id":405280,"FormularyType":"OHP","DrugName":"DROPSAFE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57273000258"},{"Id":405281,"FormularyType":"OHP","DrugName":"JUST RIGHT PST 5000","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"57511000101"},{"Id":405282,"FormularyType":"OHP","DrugName":"JUST RIGHT PST 5000","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"57511000201"},{"Id":405283,"FormularyType":"OHP","DrugName":"JUST RIGHT PST 5000","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"57511000301"},{"Id":405284,"FormularyType":"OHP","DrugName":"FLUORMX 5000 PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"57511050401"},{"Id":405285,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57513000627"},{"Id":405286,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57513000628"},{"Id":405287,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57513000629"},{"Id":405288,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57513000630"},{"Id":405289,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57513000633"},{"Id":405290,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"57513000634"},{"Id":405291,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"57513000635"},{"Id":405292,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57513000636"},{"Id":405293,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57513000637"},{"Id":405294,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57513000638"},{"Id":405295,"FormularyType":"OHP","DrugName":"ALCOHOL PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"57513000645"},{"Id":405296,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"57513000646"},{"Id":405297,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"57513000647"},{"Id":405298,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"57513000648"},{"Id":405299,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"57513000649"},{"Id":405300,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"57513000650"},{"Id":405301,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"57513000651"},{"Id":405302,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"57513000652"},{"Id":405303,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"57513000653"},{"Id":405304,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515002543"},{"Id":405305,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515002563"},{"Id":405306,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515002583"},{"Id":405307,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"57515003219"},{"Id":405308,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"57515003259"},{"Id":405309,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515003543"},{"Id":405310,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57515003553"},{"Id":405311,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515003563"},{"Id":405312,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515003583"},{"Id":405313,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515004543"},{"Id":405314,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57515004553"},{"Id":405315,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515004562"},{"Id":405316,"FormularyType":"OHP","DrugName":"1 ML SYRINGE MIS 22X1-1/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016335","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 22 G X 1-1/2\"","NDC":"57515005125"},{"Id":405317,"FormularyType":"OHP","DrugName":"3 ML SYRINGE MIS 22X1-1/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"57515005325"},{"Id":405318,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"57515007315"},{"Id":405319,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"57515007335"},{"Id":405320,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"57515007355"},{"Id":405321,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"57515007419"},{"Id":405322,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"57515007439"},{"Id":405323,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"57515007459"},{"Id":405324,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"57515008218"},{"Id":405325,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"57515008258"},{"Id":405326,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515008543"},{"Id":405327,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515008563"},{"Id":405328,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515008583"},{"Id":405329,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"57515009219"},{"Id":405330,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"57515009239"},{"Id":405331,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"57515009259"},{"Id":405332,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"57515009315"},{"Id":405333,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"57515009319"},{"Id":405334,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"57515009335"},{"Id":405335,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"57515009339"},{"Id":405336,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"57515009355"},{"Id":405337,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"57515009359"},{"Id":405338,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"57515009419"},{"Id":405339,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"57515009439"},{"Id":405340,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"57515009459"},{"Id":405341,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"57515009512"},{"Id":405342,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515009543"},{"Id":405343,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515009545"},{"Id":405344,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57515009553"},{"Id":405345,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515009562"},{"Id":405346,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515009563"},{"Id":405347,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515009565"},{"Id":405348,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515009583"},{"Id":405349,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515009585"},{"Id":405350,"FormularyType":"OHP","DrugName":"INS SYR 1ML MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"57515012315"},{"Id":405351,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"57515012335"},{"Id":405352,"FormularyType":"OHP","DrugName":"INS SY 0.5ML MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"57515012355"},{"Id":405353,"FormularyType":"OHP","DrugName":"INS SYR 1ML MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"57515012419"},{"Id":405354,"FormularyType":"OHP","DrugName":"INS SY 0.3ML MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"57515012439"},{"Id":405355,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"57515012459"},{"Id":405356,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"57515012512"},{"Id":405357,"FormularyType":"OHP","DrugName":"ULTIGUARD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515012543"},{"Id":405358,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57515012553"},{"Id":405359,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515012562"},{"Id":405360,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515012583"},{"Id":405361,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"57515017239"},{"Id":405362,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"57515017319"},{"Id":405363,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"57515017339"},{"Id":405364,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"57515017359"},{"Id":405365,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"57515017419"},{"Id":405366,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"57515017439"},{"Id":405367,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"57515017459"},{"Id":405368,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"57515018218"},{"Id":405369,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"57515018258"},{"Id":405370,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"57515019219"},{"Id":405371,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"57515019259"},{"Id":405372,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"57515019315"},{"Id":405373,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"57515019335"},{"Id":405374,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"57515019355"},{"Id":405375,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706334","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"57515025110"},{"Id":405376,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"57515025158"},{"Id":405377,"FormularyType":"OHP","DrugName":"ULTICARE PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"57515044000"},{"Id":405378,"FormularyType":"OHP","DrugName":"ULTICARE PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"57515044001"},{"Id":405379,"FormularyType":"OHP","DrugName":"ULTICARE MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"57515061005"},{"Id":405380,"FormularyType":"OHP","DrugName":"ULTICARE MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515061008"},{"Id":405381,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016388","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 5/8\"","NDC":"57515063000"},{"Id":405382,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016387","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"57515063001"},{"Id":405383,"FormularyType":"OHP","DrugName":"1ML TB SYRNG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016391","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2\"","NDC":"57515063002"},{"Id":405384,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"57515063003"},{"Id":405385,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"57515063004"},{"Id":405386,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"57515063005"},{"Id":405387,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"57515063006"},{"Id":405388,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"57515063007"},{"Id":405389,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"57515063008"},{"Id":405390,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"57515063014"},{"Id":405391,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515071000"},{"Id":405392,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515071001"},{"Id":405393,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515071002"},{"Id":405394,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515071003"},{"Id":405395,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515071004"},{"Id":405396,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515071005"},{"Id":405397,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"57515071006"},{"Id":405398,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"57515071007"},{"Id":405399,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515071008"},{"Id":405400,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"57515071009"},{"Id":405401,"FormularyType":"OHP","DrugName":"ULTICARE PEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"57515071013"},{"Id":405402,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"57515071014"},{"Id":405403,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"57515091000"},{"Id":405404,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"57515091001"},{"Id":405405,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"57515091002"},{"Id":405406,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"57515091003"},{"Id":405407,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"57515091004"},{"Id":405408,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"57515091005"},{"Id":405409,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"57515091006"},{"Id":405410,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"57515091007"},{"Id":405411,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906336","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X 1/4\" (6 MM)","NDC":"57515091008"},{"Id":405412,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906337","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 1/4\" (6 MM)","NDC":"57515091009"},{"Id":405413,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"57515091010"},{"Id":405414,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"57515091011"},{"Id":405415,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906336","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X 1/4\" (6 MM)","NDC":"57515091012"},{"Id":405416,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906337","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 1/4\" (6 MM)","NDC":"57515091013"},{"Id":405417,"FormularyType":"OHP","DrugName":"FREESTYLE LB KIT 14D/SEN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012046300","GenericName":"*CONTINUOUS GLUCOSE SYSTEM SENSOR***","NDC":"57599000101"},{"Id":405418,"FormularyType":"OHP","DrugName":"FREESTYLE LB MIS 14D/RDR","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012026200","GenericName":"*CONTINUOUS GLUCOSE SYSTEM RECEIVER***","NDC":"57599000200"},{"Id":405419,"FormularyType":"OHP","DrugName":"PRECISION LIQ GLUC/KET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"57599013901"},{"Id":405420,"FormularyType":"OHP","DrugName":"MEDISENSE LIQ GLUC-KET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"57599031201"},{"Id":405421,"FormularyType":"OHP","DrugName":"CONTROL SOL LIQ HI/MID/L","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"57599055101"},{"Id":405422,"FormularyType":"OHP","DrugName":"FREESTYLE LB KIT 2/SENSOR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012046300","GenericName":"*CONTINUOUS GLUCOSE SYSTEM SENSOR***","NDC":"57599080000"},{"Id":405423,"FormularyType":"OHP","DrugName":"FREESTYLE LB MIS 2/READER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012026200","GenericName":"*CONTINUOUS GLUCOSE SYSTEM RECEIVER***","NDC":"57599080300"},{"Id":405424,"FormularyType":"OHP","DrugName":"FREESTYLE LB KIT 3/SENSOR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012046300","GenericName":"*CONTINUOUS GLUCOSE SYSTEM SENSOR***","NDC":"57599081800"},{"Id":405425,"FormularyType":"OHP","DrugName":"FREESTYLE LB MIS 3/READER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012026200","GenericName":"*CONTINUOUS GLUCOSE SYSTEM RECEIVER***","NDC":"57599082000"},{"Id":405426,"FormularyType":"OHP","DrugName":"FREESTYLE LB KIT 2PLS/SEN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012046300","GenericName":"*CONTINUOUS GLUCOSE SYSTEM SENSOR***","NDC":"57599083500"},{"Id":405427,"FormularyType":"OHP","DrugName":"FREESTYLE LB KIT 3PLS/SEN","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202012046300","GenericName":"*CONTINUOUS GLUCOSE SYSTEM SENSOR***","NDC":"57599084400"},{"Id":405428,"FormularyType":"OHP","DrugName":"FREESTYLE TES PREC NEO","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"57599157701"},{"Id":405429,"FormularyType":"OHP","DrugName":"FREESTYLE TES PREC NEO","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"57599157904"},{"Id":405430,"FormularyType":"OHP","DrugName":"FREESTYLE KIT PREC NEO","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202010006410","GenericName":"*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","NDC":"57599517501"},{"Id":405431,"FormularyType":"OHP","DrugName":"PRECISION MIS XTRA","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202510006210","GenericName":"*BLOOD GLUCOSE/KETONE MONITORING DEVICES***","NDC":"57599881401"},{"Id":405432,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"57599889401"},{"Id":405433,"FormularyType":"OHP","DrugName":"PRECISION TES XTRA","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"57599972804"},{"Id":405434,"FormularyType":"OHP","DrugName":"PRECISION TES XTRA","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"57599987705"},{"Id":405435,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"57629010020"},{"Id":405436,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"57629010121"},{"Id":405437,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"57629050012"},{"Id":405438,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"57629060010"},{"Id":405439,"FormularyType":"OHP","DrugName":"MAGIC BULLET SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57648000201"},{"Id":405440,"FormularyType":"OHP","DrugName":"MAGIC BULLET SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57648000210"},{"Id":405441,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"57664002097"},{"Id":405442,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"57664002098"},{"Id":405443,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"57664002197"},{"Id":405444,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"57664002198"},{"Id":405445,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"57664002397"},{"Id":405446,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"57664002398"},{"Id":405447,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"57664002597"},{"Id":405448,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"57664002598"},{"Id":405449,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"57664004688"},{"Id":405450,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"57664004788"},{"Id":405451,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"57664004888"},{"Id":405452,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"57664004988"},{"Id":405453,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"57664005088"},{"Id":405454,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"57664005188"},{"Id":405455,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"57664005288"},{"Id":405456,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"57664005513"},{"Id":405457,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"57664005518"},{"Id":405458,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"57664005599"},{"Id":405459,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57664005613"},{"Id":405460,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57664005618"},{"Id":405461,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57664005699"},{"Id":405462,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57664005713"},{"Id":405463,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57664005718"},{"Id":405464,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57664005799"},{"Id":405465,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"57664010318"},{"Id":405466,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"57664010513"},{"Id":405467,"FormularyType":"OHP","DrugName":"FLURBIPROFEN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100012000310","GenericName":"FLURBIPROFEN TAB 50 MG","NDC":"57664016408"},{"Id":405468,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"57664016618"},{"Id":405469,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"57664016708"},{"Id":405470,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"57664022888"},{"Id":405471,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"57664022988"},{"Id":405472,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"57664023088"},{"Id":405473,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100110","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG","NDC":"57664023188"},{"Id":405474,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"57664023288"},{"Id":405475,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"57664023388"},{"Id":405476,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"57664033688"},{"Id":405477,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"57664033788"},{"Id":405478,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"57664033888"},{"Id":405479,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"57664033988"},{"Id":405480,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"57664034088"},{"Id":405481,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"57664034188"},{"Id":405482,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100320","GenericName":"DEXMETHYLPHENIDATE HCL TAB 2.5 MG","NDC":"57664037688"},{"Id":405483,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100330","GenericName":"DEXMETHYLPHENIDATE HCL TAB 5 MG","NDC":"57664037888"},{"Id":405484,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100340","GenericName":"DEXMETHYLPHENIDATE HCL TAB 10 MG","NDC":"57664037988"},{"Id":405485,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"57664043588"},{"Id":405486,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"57664043718"},{"Id":405487,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"57664043788"},{"Id":405488,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"57664044118"},{"Id":405489,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"57664044188"},{"Id":405490,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"57664047488"},{"Id":405491,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"57664050218"},{"Id":405492,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"57664050289"},{"Id":405493,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"57664050318"},{"Id":405494,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"57664050389"},{"Id":405495,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"57664056813"},{"Id":405496,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"57664056899"},{"Id":405497,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57664056913"},{"Id":405498,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"57664056999"},{"Id":405499,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57664057013"},{"Id":405500,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57664057018"},{"Id":405501,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"57664057099"},{"Id":405502,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 18MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100460","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG","NDC":"57664060688"},{"Id":405503,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 27MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100465","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","NDC":"57664060788"},{"Id":405504,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"57664060888"},{"Id":405505,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 54MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100480","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","NDC":"57664060988"},{"Id":405506,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"57664064108"},{"Id":405507,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"57664064208"},{"Id":405508,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"57664064308"},{"Id":405509,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"57664064408"},{"Id":405510,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"57664064508"},{"Id":405511,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"57664064608"},{"Id":405512,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"57664064708"},{"Id":405513,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"57664064888"},{"Id":405514,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"57664064988"},{"Id":405515,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000305","GenericName":"PINDOLOL TAB 5 MG","NDC":"57664065588"},{"Id":405516,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000310","GenericName":"PINDOLOL TAB 10 MG","NDC":"57664065688"},{"Id":405517,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"57664068331"},{"Id":405518,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"57664068357"},{"Id":405519,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"57664076113"},{"Id":405520,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"57664076188"},{"Id":405521,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"57664080818"},{"Id":405522,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"57664080888"},{"Id":405523,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"57664085188"},{"Id":405524,"FormularyType":"OHP","DrugName":"CHOLEXTRA POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"57771000102"},{"Id":405525,"FormularyType":"OHP","DrugName":"PURECARB POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"57771000129"},{"Id":405526,"FormularyType":"OHP","DrugName":"MALTOCARB POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"57771000141"},{"Id":405527,"FormularyType":"OHP","DrugName":"ENCALA POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"57771000145"},{"Id":405528,"FormularyType":"OHP","DrugName":"LIQUID HOPE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"57858000411"},{"Id":405529,"FormularyType":"OHP","DrugName":"NOURISH LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"57858000412"},{"Id":405530,"FormularyType":"OHP","DrugName":"KETO LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"57858000424"},{"Id":405531,"FormularyType":"OHP","DrugName":"NOURISH PEP LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"57858000427"},{"Id":405532,"FormularyType":"OHP","DrugName":"LIQUID HOPE LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"57858000428"},{"Id":405533,"FormularyType":"OHP","DrugName":"LIQ HOPE PEP LIQ BERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"57858000450"},{"Id":405534,"FormularyType":"OHP","DrugName":"AKEEGA TAB 50/500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21409902120320","GenericName":"NIRAPARIB TOSYLATE-ABIRATERONE ACETATE TAB 50-500 MG","NDC":"57894005060"},{"Id":405535,"FormularyType":"OHP","DrugName":"LAZCLUZE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360048300320","GenericName":"LAZERTINIB MESYLATE TAB 80 MG","NDC":"57894008060"},{"Id":405536,"FormularyType":"OHP","DrugName":"AKEEGA TAB 100/500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21409902120330","GenericName":"NIRAPARIB TOSYLATE-ABIRATERONE ACETATE TAB 100-500 MG","NDC":"57894010060"},{"Id":405537,"FormularyType":"OHP","DrugName":"LAZCLUZE TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360048300340","GenericName":"LAZERTINIB MESYLATE TAB 240 MG","NDC":"57894024030"},{"Id":405538,"FormularyType":"OHP","DrugName":"TREMFYA INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025054200E520","GenericName":"GUSELKUMAB SOLN PREFILLED SYRINGE 100 MG/ML","NDC":"57894064001"},{"Id":405539,"FormularyType":"OHP","DrugName":"TREMFYA INJ 100MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025054200D520","GenericName":"GUSELKUMAB SOLN AUTO-INJECTOR 100 MG/ML","NDC":"57894064006"},{"Id":405540,"FormularyType":"OHP","DrugName":"TREMFYA INJ 100MG/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025054200D225","GenericName":"GUSELKUMAB SOLN PEN-INJECTOR 100 MG/ML","NDC":"57894064011"},{"Id":405541,"FormularyType":"OHP","DrugName":"TREMFYA INJ 100MG/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025054200D225","GenericName":"GUSELKUMAB SOLN PEN-INJECTOR 100 MG/ML","NDC":"57894064099"},{"Id":405542,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"57896010201"},{"Id":405543,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"57896010205"},{"Id":405544,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"57896010210"},{"Id":405545,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"57896010220"},{"Id":405546,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"57896014001"},{"Id":405547,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN FRST AID","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"57896014309"},{"Id":405548,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN FRST AID","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"57896014314"},{"Id":405549,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"57896014514"},{"Id":405550,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"57896014609"},{"Id":405551,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"57896014614"},{"Id":405552,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"57896014701"},{"Id":405553,"FormularyType":"OHP","DrugName":"ACETAMIN CHW 80MG","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"57896014803"},{"Id":405554,"FormularyType":"OHP","DrugName":"PAIN RELIEF LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"57896016016"},{"Id":405555,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896020110"},{"Id":405556,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896020401"},{"Id":405557,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896020405"},{"Id":405558,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896020420"},{"Id":405559,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB EXT STR","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"57896021601"},{"Id":405560,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896021901"},{"Id":405561,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896021905"},{"Id":405562,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896021910"},{"Id":405563,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896021920"},{"Id":405564,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896021950"},{"Id":405565,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896022201"},{"Id":405566,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896022210"},{"Id":405567,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896022220"},{"Id":405568,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"57896025101"},{"Id":405569,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"57896026801"},{"Id":405570,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"57896030401"},{"Id":405571,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"57896030410"},{"Id":405572,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"57896031703"},{"Id":405573,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"57896031706"},{"Id":405574,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"57896031901"},{"Id":405575,"FormularyType":"OHP","DrugName":"TRAVEL-EASE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"57896037801"},{"Id":405576,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"57896040101"},{"Id":405577,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"57896040103"},{"Id":405578,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"57896040110"},{"Id":405579,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"57896040120"},{"Id":405580,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"57896040125"},{"Id":405581,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"57896041110"},{"Id":405582,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"57896041316"},{"Id":405583,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"57896042101"},{"Id":405584,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"57896042110"},{"Id":405585,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"57896042120"},{"Id":405586,"FormularyType":"OHP","DrugName":"DOCUSATE SOD LIQ 50MG/5ML","DosageForm":"LIQD - Liquid","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300910","GenericName":"DOCUSATE SODIUM LIQUID 150 MG/15ML","NDC":"57896042316"},{"Id":405587,"FormularyType":"OHP","DrugName":"STOOL SOFT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"57896042601"},{"Id":405588,"FormularyType":"OHP","DrugName":"GERI-KOT TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"57896043401"},{"Id":405589,"FormularyType":"OHP","DrugName":"GERI-KOT TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"57896043410"},{"Id":405590,"FormularyType":"OHP","DrugName":"GERI-KOT TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"57896043420"},{"Id":405591,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"57896044101"},{"Id":405592,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"57896044110"},{"Id":405593,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"57896044120"},{"Id":405594,"FormularyType":"OHP","DrugName":"BISACODYL TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"57896044126"},{"Id":405595,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57896044301"},{"Id":405596,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57896044305"},{"Id":405597,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"57896044312"},{"Id":405598,"FormularyType":"OHP","DrugName":"GERI-KOT TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"57896045401"},{"Id":405599,"FormularyType":"OHP","DrugName":"GERI-KOT TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"57896045420"},{"Id":405600,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"57896045909"},{"Id":405601,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"57896045950"},{"Id":405602,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"57896046208"},{"Id":405603,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"57896047208"},{"Id":405604,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"57896048914"},{"Id":405605,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"57896048930"},{"Id":405606,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"57896049003"},{"Id":405607,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"57896054001"},{"Id":405608,"FormularyType":"OHP","DrugName":"SENNA-PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"57896055501"},{"Id":405609,"FormularyType":"OHP","DrugName":"SENNA-PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"57896055506"},{"Id":405610,"FormularyType":"OHP","DrugName":"SENNA-PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"57896055510"},{"Id":405611,"FormularyType":"OHP","DrugName":"SENNA-PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"57896055520"},{"Id":405612,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"57896057501"},{"Id":405613,"FormularyType":"OHP","DrugName":"NEPHRO TAB VITAMINS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"57896060501"},{"Id":405614,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896061512"},{"Id":405615,"FormularyType":"OHP","DrugName":"GERI-LANTA SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"57896062912"},{"Id":405616,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"57896063412"},{"Id":405617,"FormularyType":"OHP","DrugName":"ANTACID & SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"57896063910"},{"Id":405618,"FormularyType":"OHP","DrugName":"GERI-MOX SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"57896063912"},{"Id":405619,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896064712"},{"Id":405620,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896064812"},{"Id":405621,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896064910"},{"Id":405622,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896064912"},{"Id":405623,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896064916"},{"Id":405624,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"57896064928"},{"Id":405625,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"57896065803"},{"Id":405626,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"57896065809"},{"Id":405627,"FormularyType":"OHP","DrugName":"COMP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"57896068301"},{"Id":405628,"FormularyType":"OHP","DrugName":"GERI-DRYL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"57896068310"},{"Id":405629,"FormularyType":"OHP","DrugName":"GERI-DRYL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"57896068340"},{"Id":405630,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"57896070301"},{"Id":405631,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"57896070310"},{"Id":405632,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"57896070320"},{"Id":405633,"FormularyType":"OHP","DrugName":"IRON SUPPMNT SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"57896070916"},{"Id":405634,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"57896072401"},{"Id":405635,"FormularyType":"OHP","DrugName":"OYS SHEL CAL TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"57896073101"},{"Id":405636,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"57896074101"},{"Id":405637,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"57896074106"},{"Id":405638,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"57896074201"},{"Id":405639,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"57896074206"},{"Id":405640,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"57896074210"},{"Id":405641,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"57896074225"},{"Id":405642,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"57896074275"},{"Id":405643,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"57896074606"},{"Id":405644,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"57896074615"},{"Id":405645,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB +D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630365","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 600 MG-5 MCG (200 UNIT)","NDC":"57896074706"},{"Id":405646,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB + D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"57896074801"},{"Id":405647,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB + D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"57896074806"},{"Id":405648,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"57896075301"},{"Id":405649,"FormularyType":"OHP","DrugName":"SORBITOL SOL 70%","DosageForm":"SOLN - Solution","Strength":"70","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600070002070","GenericName":"SORBITOL RECTAL SOLUTION 70%","NDC":"57896075816"},{"Id":405650,"FormularyType":"OHP","DrugName":"CALCIUM CARB CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"57896076315"},{"Id":405651,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"57896078572"},{"Id":405652,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1250MCG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"57896081512"},{"Id":405653,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"57896083403"},{"Id":405654,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"57896083409"},{"Id":405655,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"57896085101"},{"Id":405656,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"57896085301"},{"Id":405657,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"57896085401"},{"Id":405658,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"57896085601"},{"Id":405659,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"57896086406"},{"Id":405660,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"57896086420"},{"Id":405661,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"57896087401"},{"Id":405662,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"57896087601"},{"Id":405663,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"57896087620"},{"Id":405664,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"57896088001"},{"Id":405665,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"57896088101"},{"Id":405666,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"57896088406"},{"Id":405667,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"57896088409"},{"Id":405668,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"57896088418"},{"Id":405669,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"57896088601"},{"Id":405670,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"57896089601"},{"Id":405671,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"57896090101"},{"Id":405672,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"57896090110"},{"Id":405673,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"57896091136"},{"Id":405674,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"57896092101"},{"Id":405675,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"57896092110"},{"Id":405676,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"57896092120"},{"Id":405677,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"57896094101"},{"Id":405678,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"57896094105"},{"Id":405679,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"57896094110"},{"Id":405680,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"57896094120"},{"Id":405681,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"57896094150"},{"Id":405682,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"57896097401"},{"Id":405683,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"57896097410"},{"Id":405684,"FormularyType":"OHP","DrugName":"GERI-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"57896098016"},{"Id":405685,"FormularyType":"OHP","DrugName":"ASPIRIN EC TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57896098101"},{"Id":405686,"FormularyType":"OHP","DrugName":"ASPIRIN EC TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57896098110"},{"Id":405687,"FormularyType":"OHP","DrugName":"ASPIRIN EC TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57896098112"},{"Id":405688,"FormularyType":"OHP","DrugName":"ASPIRIN EC TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57896098120"},{"Id":405689,"FormularyType":"OHP","DrugName":"ASPIRIN EC TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57896098130"},{"Id":405690,"FormularyType":"OHP","DrugName":"ASPIRIN ADLT TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"57896098312"},{"Id":405691,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"57896099201"},{"Id":405692,"FormularyType":"OHP","DrugName":"IMBRUVICA SUS 70MG/ML","DosageForm":"SUSP - Suspension","Strength":"70","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532133001820","GenericName":"IBRUTINIB ORAL SUSP 70 MG/ML","NDC":"57962000712"},{"Id":405693,"FormularyType":"OHP","DrugName":"IMBRUVICA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532133000110","GenericName":"IBRUTINIB CAP 70 MG","NDC":"57962007028"},{"Id":405694,"FormularyType":"OHP","DrugName":"IMBRUVICA CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532133000120","GenericName":"IBRUTINIB CAP 140 MG","NDC":"57962014009"},{"Id":405695,"FormularyType":"OHP","DrugName":"IMBRUVICA CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532133000120","GenericName":"IBRUTINIB CAP 140 MG","NDC":"57962014012"},{"Id":405696,"FormularyType":"OHP","DrugName":"MECLIZINE 25 TAB","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"57963010101"},{"Id":405697,"FormularyType":"OHP","DrugName":"DILANTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"58151011001"},{"Id":405698,"FormularyType":"OHP","DrugName":"DILANTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"58151011010"},{"Id":405699,"FormularyType":"OHP","DrugName":"DILANTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"58151011032"},{"Id":405700,"FormularyType":"OHP","DrugName":"DILANTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"58151011088"},{"Id":405701,"FormularyType":"OHP","DrugName":"DILANTIN-125 SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"O","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030001810","GenericName":"PHENYTOIN SUSP 125 MG/5ML","NDC":"58151011535"},{"Id":405702,"FormularyType":"OHP","DrugName":"DILANTIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200105","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 30 MG","NDC":"58151011801"},{"Id":405703,"FormularyType":"OHP","DrugName":"MOVE ALONG TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"58154010101"},{"Id":405704,"FormularyType":"OHP","DrugName":"PENMENVY INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040621900","GenericName":"MENINGOCOCCAL ACWY (OLIGO CONJ)-MENING B (RCMB) VACC FOR INJ","NDC":"58160075715"},{"Id":405705,"FormularyType":"OHP","DrugName":"INFANRIX INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990003201840","GenericName":"DIPH, ACELLULAR PERT & TET TOX INJ 25 LF-58 MCG-10 LF/0.5ML","NDC":"58160081043"},{"Id":405706,"FormularyType":"OHP","DrugName":"INFANRIX INJ","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"18990003201840","GenericName":"DIPH, ACELLULAR PERT & TET TOX INJ 25 LF-58 MCG-10 LF/0.5ML","NDC":"58160081052"},{"Id":405707,"FormularyType":"OHP","DrugName":"TWINRIX INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710990205E620","GenericName":"HEP A-HEP B VACCINE SUSP PREF SYR 720-20 ELU-MCG/ML","NDC":"58160081543"},{"Id":405708,"FormularyType":"OHP","DrugName":"TWINRIX INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710990205E620","GenericName":"HEP A-HEP B VACCINE SUSP PREF SYR 720-20 ELU-MCG/ML","NDC":"58160081552"},{"Id":405709,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 10/0.5ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E625","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 10 MCG/0.5ML","NDC":"58160082043"},{"Id":405710,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 10/0.5ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E625","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 10 MCG/0.5ML","NDC":"58160082052"},{"Id":405711,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 20MCG/ML","DosageForm":"SUSP - Suspension","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201830","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 20 MCG/ML","NDC":"58160082101"},{"Id":405712,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 20MCG/ML","DosageForm":"SUSP - Suspension","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100010201830","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP 20 MCG/ML","NDC":"58160082111"},{"Id":405713,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 20MCG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E630","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 20 MCG/ML","NDC":"58160082143"},{"Id":405714,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 20MCG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E630","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 20 MCG/ML","NDC":"58160082151"},{"Id":405715,"FormularyType":"OHP","DrugName":"ENGERIX-B INJ 20MCG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"20","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710001020E630","GenericName":"HEPATITIS B VACCINE (RECOMBINANT) SUSP PREF SYR 20 MCG/ML","NDC":"58160082152"},{"Id":405716,"FormularyType":"OHP","DrugName":"SHINGRIX INJ 50/0.5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"50","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100095401920","GenericName":"ZOSTER VAC RECOMBINANT ADJUVANTED FOR IM INJ 50 MCG/0.5ML","NDC":"58160082311"},{"Id":405717,"FormularyType":"OHP","DrugName":"PRIORIX INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17109903101901","GenericName":"MEASLES-MUMPS-RUBELLA VIRUS VACCINES FOR SUBCUTANEOUS SUSP","NDC":"58160082415"},{"Id":405718,"FormularyType":"OHP","DrugName":"HAVRIX INJ 720UNIT","DosageForm":"SUSY - Susp Pref Syr","Strength":"720","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E660","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 720 EL UNIT/0.5ML","NDC":"58160082543"},{"Id":405719,"FormularyType":"OHP","DrugName":"HAVRIX INJ 720UNIT","DosageForm":"SUSY - Susp Pref Syr","Strength":"720","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E660","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 720 EL UNIT/0.5ML","NDC":"58160082552"},{"Id":405720,"FormularyType":"OHP","DrugName":"HAVRIX INJ 1440UNIT","DosageForm":"SUSY - Susp Pref Syr","Strength":"1440","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E680","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 1440 EL UNIT/ML","NDC":"58160082643"},{"Id":405721,"FormularyType":"OHP","DrugName":"HAVRIX INJ 1440UNIT","DosageForm":"SUSY - Susp Pref Syr","Strength":"1440","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000800E680","GenericName":"HEPATITIS A VACCINE SUSP PREFILLED SYR 1440 EL UNIT/ML","NDC":"58160082652"},{"Id":405722,"FormularyType":"OHP","DrugName":"MENVEO SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"55","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040482020","GenericName":"MENINGOCOCCAL (A, C, Y, AND W-135) OLIGO CONJ VAC IM SOLN","NDC":"58160082703"},{"Id":405723,"FormularyType":"OHP","DrugName":"MENVEO SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"55","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040482020","GenericName":"MENINGOCOCCAL (A, C, Y, AND W-135) OLIGO CONJ VAC IM SOLN","NDC":"58160082730"},{"Id":405724,"FormularyType":"OHP","DrugName":"PRIORIX INJ","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17109903101901","GenericName":"MEASLES-MUMPS-RUBELLA VIRUS VACCINES FOR SUBCUTANEOUS SUSP","NDC":"58160083103"},{"Id":405725,"FormularyType":"OHP","DrugName":"BOOSTRIX INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1899000322E620","GenericName":"TET-DIPH-ACELL PERTUSS AD PREF SYR 5-2.5-18.5 LF-MCG/0.5ML","NDC":"58160084243"},{"Id":405726,"FormularyType":"OHP","DrugName":"BOOSTRIX INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"TOXOIDS","DrugSubClass":"TOXOID COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1899000322E620","GenericName":"TET-DIPH-ACELL PERTUSS AD PREF SYR 5-2.5-18.5 LF-MCG/0.5ML","NDC":"58160084252"},{"Id":405727,"FormularyType":"OHP","DrugName":"AREXVY INJ 120MCG","DosageForm":"SUSR - Suspension Reconstituted","Strength":"120","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"50","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100072101920","GenericName":"RSVPREF3 VACCINE RECOMB ADJUVANTED FOR IM SUSP 120 MCG/0.5ML","NDC":"58160084811"},{"Id":405728,"FormularyType":"OHP","DrugName":"SHINGRIX INJ 50/0.5ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"50","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710009540E620","GenericName":"ZOSTER VAC RECOMB ADJUVANTED IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"58160084943"},{"Id":405729,"FormularyType":"OHP","DrugName":"SHINGRIX INJ 50/0.5ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"50","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710009540E620","GenericName":"ZOSTER VAC RECOMB ADJUVANTED IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"58160084952"},{"Id":405730,"FormularyType":"OHP","DrugName":"FLUARIX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"58160091241"},{"Id":405731,"FormularyType":"OHP","DrugName":"FLUARIX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002021E620","GenericName":"INFLUENZA VIRUS VACCINE SPLIT PF SUSP PREF SYRINGE 0.5 ML","NDC":"58160091252"},{"Id":405732,"FormularyType":"OHP","DrugName":"MENVEO INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"55","AgeMaxUnit":"Y","GenericProductIdentifier":"17200040482100","GenericName":"MENINGOCOCCAL (A, C, Y, AND W-135) OLIGO CONJ VAC FOR INJ","NDC":"58160095509"},{"Id":405733,"FormularyType":"OHP","DrugName":"BEXSERO INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"1720004015E620","GenericName":"MENINGOCOCCAL VAC B (RECOMB OMV ADJUV) INJ PREFILLED SYRINGE","NDC":"58160097602"},{"Id":405734,"FormularyType":"OHP","DrugName":"BEXSERO INJ","DosageForm":"SUSY - Susp Pref Syr","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"BACTERIAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"19","AgeMinUnit":"Y","AgeMax":"25","AgeMaxUnit":"Y","GenericProductIdentifier":"1720004015E620","GenericName":"MENINGOCOCCAL VAC B (RECOMB OMV ADJUV) INJ PREFILLED SYRINGE","NDC":"58160097620"},{"Id":405735,"FormularyType":"OHP","DrugName":"ADEK CHW PLUS ZN","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIPLE VITAMINS W/ MINERALS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78310000000500","GenericName":"*MULTIPLE VITAMINS W/ MINERALS CHEW TAB**","NDC":"58204000438"},{"Id":405736,"FormularyType":"OHP","DrugName":"BRIXADI SOL 8/0.16ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"8","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E560","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 8 MG/0.16ML","NDC":"58284020801"},{"Id":405737,"FormularyType":"OHP","DrugName":"BRIXADI SOL 16/0.32","DosageForm":"SOSY - Soln Pref Syr","Strength":"16","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E565","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 16 MG/0.32ML","NDC":"58284021601"},{"Id":405738,"FormularyType":"OHP","DrugName":"BRIXADI SOL 16/0.32","DosageForm":"SOSY - Soln Pref Syr","Strength":"16","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E565","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 16 MG/0.32ML","NDC":"58284021691"},{"Id":405739,"FormularyType":"OHP","DrugName":"BRIXADI SOL 24/0.48","DosageForm":"SOSY - Soln Pref Syr","Strength":"24","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E570","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 24 MG/0.48ML","NDC":"58284022401"},{"Id":405740,"FormularyType":"OHP","DrugName":"BRIXADI SOL 24/0.48","DosageForm":"SOSY - Soln Pref Syr","Strength":"24","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E570","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 24 MG/0.48ML","NDC":"58284022491"},{"Id":405741,"FormularyType":"OHP","DrugName":"BRIXADI SOL 128/0.36","DosageForm":"SOSY - Soln Pref Syr","Strength":"128","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E523","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 128 MG/0.36ML","NDC":"58284022801"},{"Id":405742,"FormularyType":"OHP","DrugName":"BRIXADI SOL 128/0.36","DosageForm":"SOSY - Soln Pref Syr","Strength":"128","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E523","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 128 MG/0.36ML","NDC":"58284022891"},{"Id":405743,"FormularyType":"OHP","DrugName":"BRIXADI SOL 32/0.64","DosageForm":"SOSY - Soln Pref Syr","Strength":"32","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E575","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 32 MG/0.64ML","NDC":"58284023201"},{"Id":405744,"FormularyType":"OHP","DrugName":"BRIXADI SOL 32/0.64","DosageForm":"SOSY - Soln Pref Syr","Strength":"32","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E575","GenericName":"BUPRENORPHINE EXT REL SOLN PREF SYR (WEEKLY) 32 MG/0.64ML","NDC":"58284023291"},{"Id":405745,"FormularyType":"OHP","DrugName":"BRIXADI SOL 64/0.18","DosageForm":"SOSY - Soln Pref Syr","Strength":"64","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E515","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 64 MG/0.18ML","NDC":"58284026401"},{"Id":405746,"FormularyType":"OHP","DrugName":"BRIXADI SOL 64/0.18","DosageForm":"SOSY - Soln Pref Syr","Strength":"64","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E515","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 64 MG/0.18ML","NDC":"58284026491"},{"Id":405747,"FormularyType":"OHP","DrugName":"BRIXADI SOL 96/0.27","DosageForm":"SOSY - Soln Pref Syr","Strength":"96","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E518","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 96 MG/0.27ML","NDC":"58284029601"},{"Id":405748,"FormularyType":"OHP","DrugName":"BRIXADI SOL 96/0.27","DosageForm":"SOSY - Soln Pref Syr","Strength":"96","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6520001000E518","GenericName":"BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 96 MG/0.27ML","NDC":"58284029691"},{"Id":405749,"FormularyType":"OHP","DrugName":"ENBREL INJ 25/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000E525","GenericName":"ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML","NDC":"58406001001"},{"Id":405750,"FormularyType":"OHP","DrugName":"ENBREL INJ 25/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000E525","GenericName":"ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML","NDC":"58406001004"},{"Id":405751,"FormularyType":"OHP","DrugName":"ENBREL INJ 50MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000E530","GenericName":"ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML","NDC":"58406002101"},{"Id":405752,"FormularyType":"OHP","DrugName":"ENBREL INJ 50MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000E530","GenericName":"ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML","NDC":"58406002104"},{"Id":405753,"FormularyType":"OHP","DrugName":"ENBREL SRCLK INJ 50MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000D530","GenericName":"ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML","NDC":"58406003201"},{"Id":405754,"FormularyType":"OHP","DrugName":"ENBREL SRCLK INJ 50MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000D530","GenericName":"ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML","NDC":"58406003204"},{"Id":405755,"FormularyType":"OHP","DrugName":"ENBREL MINI INJ 50MG/ML","DosageForm":"SOCT - Soln Cartridge","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000E230","GenericName":"ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML","NDC":"58406004401"},{"Id":405756,"FormularyType":"OHP","DrugName":"ENBREL MINI INJ 50MG/ML","DosageForm":"SOCT - Soln Cartridge","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6629003000E230","GenericName":"ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML","NDC":"58406004404"},{"Id":405757,"FormularyType":"OHP","DrugName":"ENBREL INJ 25MG","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66290030002015","GenericName":"ETANERCEPT SUBCUTANEOUS INJ 25 MG/0.5ML","NDC":"58406005501"},{"Id":405758,"FormularyType":"OHP","DrugName":"ENBREL INJ 25MG","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66290030002015","GenericName":"ETANERCEPT SUBCUTANEOUS INJ 25 MG/0.5ML","NDC":"58406005504"},{"Id":405759,"FormularyType":"OHP","DrugName":"CABLIVI KIT 11MG","DosageForm":"KIT - Kit","Strength":"11","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85151020806420","GenericName":"CAPLACIZUMAB-YHDP FOR INJ KIT 11 MG","NDC":"58468022501"},{"Id":405760,"FormularyType":"OHP","DrugName":"WAYRILZ TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATAOLOGIC - TYROSINE KINASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85752050000340","GenericName":"RILZABRUTINIB TAB 400 MG","NDC":"58468025106"},{"Id":405761,"FormularyType":"OHP","DrugName":"CAPRELSA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533085000320","GenericName":"VANDETANIB TAB 100 MG","NDC":"58468782003"},{"Id":405762,"FormularyType":"OHP","DrugName":"CAPRELSA TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533085000340","GenericName":"VANDETANIB TAB 300 MG","NDC":"58468784003"},{"Id":405763,"FormularyType":"OHP","DrugName":"KPN PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000303","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.1 MG***","NDC":"58487000331"},{"Id":405764,"FormularyType":"OHP","DrugName":"KPN PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000303","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.1 MG***","NDC":"58487000332"},{"Id":405765,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"58487000381"},{"Id":405766,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000310","GenericName":"NIACINAMIDE TAB 100 MG","NDC":"58487000391"},{"Id":405767,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100320","GenericName":"THIAMINE HCL TAB 50 MG","NDC":"58487000801"},{"Id":405768,"FormularyType":"OHP","DrugName":"VITAMIN B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"58487000811"},{"Id":405769,"FormularyType":"OHP","DrugName":"VITAMIN B 6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"58487000871"},{"Id":405770,"FormularyType":"OHP","DrugName":"VITAMIN B 6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"58487000872"},{"Id":405771,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"58487000881"},{"Id":405772,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"58487000882"},{"Id":405773,"FormularyType":"OHP","DrugName":"PSYLLIUM SEE POW 100%","DosageForm":"POWD - Powder","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102999","GenericName":"PSYLLIUM POWDER 100%","NDC":"58487001223"},{"Id":405774,"FormularyType":"OHP","DrugName":"NIACIN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000320","GenericName":"NIACIN TAB 50 MG","NDC":"58487001331"},{"Id":405775,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"58487001341"},{"Id":405776,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"58487001342"},{"Id":405777,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"58487001343"},{"Id":405778,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"58487001471"},{"Id":405779,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"58487001472"},{"Id":405780,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"58487001631"},{"Id":405781,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"58487001633"},{"Id":405782,"FormularyType":"OHP","DrugName":"DELTA D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"58487001702"},{"Id":405783,"FormularyType":"OHP","DrugName":"DELTA D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"58487001703"},{"Id":405784,"FormularyType":"OHP","DrugName":"ULTRAMINO POW SOY PROT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"58487001943"},{"Id":405785,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"58487002371"},{"Id":405786,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"58487002373"},{"Id":405787,"FormularyType":"OHP","DrugName":"VITAMIN E TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000320","GenericName":"VITAMIN E TAB 400 UNIT","NDC":"58487002451"},{"Id":405788,"FormularyType":"OHP","DrugName":"PRENATAL FRM TAB A-FREE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512050000310","GenericName":"*PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB 9-0.267 MG***","NDC":"58487002831"},{"Id":405789,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"58487002841"},{"Id":405790,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"58487002842"},{"Id":405791,"FormularyType":"OHP","DrugName":"CA CITRATE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000303","GenericName":"CALCIUM CITRATE TAB 250 MG","NDC":"58487002843"},{"Id":405792,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"58487003021"},{"Id":405793,"FormularyType":"OHP","DrugName":"VITAMIN D2 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000305","GenericName":"ERGOCALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"58487003122"},{"Id":405794,"FormularyType":"OHP","DrugName":"PRENATAL ONE TAB DAILY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"58487003131"},{"Id":405795,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000303","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 6.75-0.2 MG***","NDC":"58487003501"},{"Id":405796,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000303","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 6.75-0.2 MG***","NDC":"58487003502"},{"Id":405797,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000303","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 6.75-0.2 MG***","NDC":"58487003503"},{"Id":405798,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 3000UNIT","DosageForm":"TABS - Tablet","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000344","GenericName":"CHOLECALCIFEROL TAB 75 MCG (3000 UNIT)","NDC":"58487003691"},{"Id":405799,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"58487003702"},{"Id":405800,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"58602000640"},{"Id":405801,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"58602000739"},{"Id":405802,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"58602042324"},{"Id":405803,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"58602044509"},{"Id":405804,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"58602044540"},{"Id":405805,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"58602044594"},{"Id":405806,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"58602060407"},{"Id":405807,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"58602070204"},{"Id":405808,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"58602070219"},{"Id":405809,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"58602070221"},{"Id":405810,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"58602070238"},{"Id":405811,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"58602070240"},{"Id":405812,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"58602070284"},{"Id":405813,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"58602070515"},{"Id":405814,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"58602070519"},{"Id":405815,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"58602070584"},{"Id":405816,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"58602070653"},{"Id":405817,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"58602071121"},{"Id":405818,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"58602071129"},{"Id":405819,"FormularyType":"OHP","DrugName":"ACETAMIN ER TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"58602073094"},{"Id":405820,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"58602075521"},{"Id":405821,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"58602075536"},{"Id":405822,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"58602077321"},{"Id":405823,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"58602080501"},{"Id":405824,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"58602080502"},{"Id":405825,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"58602080503"},{"Id":405826,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"58602080527"},{"Id":405827,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"58602080961"},{"Id":405828,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"58607011310"},{"Id":405829,"FormularyType":"OHP","DrugName":"MYNEPHRON CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000130","GenericName":"*B-COMPLEX W/ C & FOLIC ACID CAP 1 MG***","NDC":"58607018510"},{"Id":405830,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"58657012012"},{"Id":405831,"FormularyType":"OHP","DrugName":"THRIVITE RX TAB 29-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512010000330","GenericName":"*PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG***","NDC":"58657013390"},{"Id":405832,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"58657015101"},{"Id":405833,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"58657015110"},{"Id":405834,"FormularyType":"OHP","DrugName":"SODIUM FLUOR CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000505","GenericName":"SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)","NDC":"58657016012"},{"Id":405835,"FormularyType":"OHP","DrugName":"SODIUM FLUOR CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000510","GenericName":"SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)","NDC":"58657016110"},{"Id":405836,"FormularyType":"OHP","DrugName":"SODIUM FLUOR CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000510","GenericName":"SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)","NDC":"58657016112"},{"Id":405837,"FormularyType":"OHP","DrugName":"SODIUM FLUOR CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000515","GenericName":"SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","NDC":"58657016212"},{"Id":405838,"FormularyType":"OHP","DrugName":"MULTI VIT/FL CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000505","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***","NDC":"58657016301"},{"Id":405839,"FormularyType":"OHP","DrugName":"MULTI VIT/FL CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000505","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***","NDC":"58657016390"},{"Id":405840,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000510","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***","NDC":"58657016401"},{"Id":405841,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000510","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***","NDC":"58657016490"},{"Id":405842,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000520","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","NDC":"58657016501"},{"Id":405843,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000520","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","NDC":"58657016590"},{"Id":405844,"FormularyType":"OHP","DrugName":"M-NATAL PLUS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"58657017001"},{"Id":405845,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"58657031016"},{"Id":405846,"FormularyType":"OHP","DrugName":"K CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202022002025","GenericName":"POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML","NDC":"58657031216"},{"Id":405847,"FormularyType":"OHP","DrugName":"SOD FLUORIDE DRO 0.5MG/ML","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020002050","GenericName":"SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF)","NDC":"58657032250"},{"Id":405848,"FormularyType":"OHP","DrugName":"TRI-VIT/FLUO DRO 0.25MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"2","AgeMaxUnit":"Y","GenericProductIdentifier":"78440500002010","GenericName":"*PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML***","NDC":"58657032350"},{"Id":405849,"FormularyType":"OHP","DrugName":"TRI-VIT/FLUO DRO 0.5MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"2","AgeMaxUnit":"Y","GenericProductIdentifier":"78440500002020","GenericName":"*PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.5 MG/ML***","NDC":"58657032450"},{"Id":405850,"FormularyType":"OHP","DrugName":"MULTIVIT/FL DRO 0.25MG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000002005","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***","NDC":"58657032550"},{"Id":405851,"FormularyType":"OHP","DrugName":"MULTI-VIT/FL DRO 0.5MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000002010","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML***","NDC":"58657032650"},{"Id":405852,"FormularyType":"OHP","DrugName":"MULTI-VIT/FL DRO /FE 0.25","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MULTI VITAMINS W/FL & FE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78450000002008","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**","NDC":"58657032750"},{"Id":405853,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"58657048707"},{"Id":405854,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"58657048901"},{"Id":405855,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"58657048903"},{"Id":405856,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"58657048907"},{"Id":405857,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"58657051808"},{"Id":405858,"FormularyType":"OHP","DrugName":"M-PAP LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"58657052404"},{"Id":405859,"FormularyType":"OHP","DrugName":"M-PAP LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"58657052416"},{"Id":405860,"FormularyType":"OHP","DrugName":"M-PAP LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"58657052504"},{"Id":405861,"FormularyType":"OHP","DrugName":"M-PAP LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"58657052516"},{"Id":405862,"FormularyType":"OHP","DrugName":"M-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"58657052804"},{"Id":405863,"FormularyType":"OHP","DrugName":"M-DRYL LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"58657052816"},{"Id":405864,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"58657060201"},{"Id":405865,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"58657060250"},{"Id":405866,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"58657060301"},{"Id":405867,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"58657060350"},{"Id":405868,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"58657060401"},{"Id":405869,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"58657060450"},{"Id":405870,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"58657064701"},{"Id":405871,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"58657064710"},{"Id":405872,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"58657064750"},{"Id":405873,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"58657064801"},{"Id":405874,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"58657064810"},{"Id":405875,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"58657064850"},{"Id":405876,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"58657064901"},{"Id":405877,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"58657064910"},{"Id":405878,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"58657064950"},{"Id":405879,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"58657067601"},{"Id":405880,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"58657069716"},{"Id":405881,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000335","GenericName":"METFORMIN HCL TAB 750 MG","NDC":"58657072730"},{"Id":405882,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"58657073001"},{"Id":405883,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"58657073101"},{"Id":405884,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"58657073110"},{"Id":405885,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"58657073201"},{"Id":405886,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"58657073210"},{"Id":405887,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"58657073501"},{"Id":405888,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"58657073601"},{"Id":405889,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"58657073701"},{"Id":405890,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"58657073801"},{"Id":405891,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000301","GenericName":"METRONIDAZOLE TAB 125 MG","NDC":"58657073956"},{"Id":405892,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"58657074001"},{"Id":405893,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"58657074101"},{"Id":405894,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"58657074201"},{"Id":405895,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"58657090601"},{"Id":405896,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"58657090610"},{"Id":405897,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"58657090701"},{"Id":405898,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"58657090710"},{"Id":405899,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"58657090801"},{"Id":405900,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"58657090810"},{"Id":405901,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"58657093001"},{"Id":405902,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"58657093005"},{"Id":405903,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"58657093101"},{"Id":405904,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"58657093105"},{"Id":405905,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"58657093201"},{"Id":405906,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"58657093205"},{"Id":405907,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"58657093301"},{"Id":405908,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"58657093305"},{"Id":405909,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"58657093401"},{"Id":405910,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"58657093405"},{"Id":405911,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"58657093501"},{"Id":405912,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"58657093503"},{"Id":405913,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"58657093601"},{"Id":405914,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"58657093603"},{"Id":405915,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"58657093703"},{"Id":405916,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"58657093710"},{"Id":405917,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"58657093803"},{"Id":405918,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"58657093810"},{"Id":405919,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"58657094001"},{"Id":405920,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"58657094010"},{"Id":405921,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"58657094101"},{"Id":405922,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"58657094110"},{"Id":405923,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"58657094201"},{"Id":405924,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"58657094210"},{"Id":405925,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"58765000005"},{"Id":405926,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"58765000006"},{"Id":405927,"FormularyType":"OHP","DrugName":"VITAMIN B-12 SUB 1000MCG","DosageForm":"SUBL - Tab Sublingual","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000705","GenericName":"CYANOCOBALAMIN SL TAB 1000 MCG","NDC":"58765000054"},{"Id":405928,"FormularyType":"OHP","DrugName":"SCANDISHAKE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"58914082018"},{"Id":405929,"FormularyType":"OHP","DrugName":"SCANDICAL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"58914083008"},{"Id":405930,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"58980001110"},{"Id":405931,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1GM","DosageForm":"SUPP - Suppository","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005206","GenericName":"GLYCERIN SUPPOS 1 GM","NDC":"58980040912"},{"Id":405932,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1GM","DosageForm":"SUPP - Suppository","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005206","GenericName":"GLYCERIN SUPPOS 1 GM","NDC":"58980040925"},{"Id":405933,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"58980041012"},{"Id":405934,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"58980041025"},{"Id":405935,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"58980041050"},{"Id":405936,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"58980041501"},{"Id":405937,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"58980041504"},{"Id":405938,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"58980041508"},{"Id":405939,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"58980041512"},{"Id":405940,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"58980041516"},{"Id":405941,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"58980041550"},{"Id":405942,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 10MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A710","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 10 MG","NDC":"59011041010"},{"Id":405943,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 10MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A710","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 10 MG","NDC":"59011041020"},{"Id":405944,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 15MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A715","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 15 MG","NDC":"59011041510"},{"Id":405945,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 15MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A715","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 15 MG","NDC":"59011041520"},{"Id":405946,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 20MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A720","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 20 MG","NDC":"59011042010"},{"Id":405947,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 20MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A720","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 20 MG","NDC":"59011042020"},{"Id":405948,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 30MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A730","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 30 MG","NDC":"59011043010"},{"Id":405949,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 30MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A730","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 30 MG","NDC":"59011043020"},{"Id":405950,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 40MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A740","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 40 MG","NDC":"59011044010"},{"Id":405951,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 40MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A740","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 40 MG","NDC":"59011044020"},{"Id":405952,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 60MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A760","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 60 MG","NDC":"59011046010"},{"Id":405953,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 60MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A760","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 60 MG","NDC":"59011046020"},{"Id":405954,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 80MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A780","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 80 MG","NDC":"59011048010"},{"Id":405955,"FormularyType":"OHP","DrugName":"OXYCONTIN TAB 80MG ER","DosageForm":"T12A - Tab 12HR Deter","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6510007510A780","GenericName":"OXYCODONE HCL TAB ER 12HR DETER 80 MG","NDC":"59011048020"},{"Id":405956,"FormularyType":"OHP","DrugName":"ZURNAI INJ 1.5/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340001810D520","GenericName":"NALMEFENE HCL SOLN AUTO-INJECTOR 1.5 MG/0.5ML (BASE EQUIV)","NDC":"59011096201"},{"Id":405957,"FormularyType":"OHP","DrugName":"PRENATOL-M TAB 27-1.2MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000325","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1.2 MG***","NDC":"59088000954"},{"Id":405958,"FormularyType":"OHP","DrugName":"PRENATRIX TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"59088016654"},{"Id":405959,"FormularyType":"OHP","DrugName":"PRENATRYL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"59088016954"},{"Id":405960,"FormularyType":"OHP","DrugName":"LIDOTRAL GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060104030","GenericName":"LIDOCAINE HCL GEL 5%","NDC":"59088020407"},{"Id":405961,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"59088022008"},{"Id":405962,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.035%","DosageForm":"CREA - Cream","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003715","GenericName":"CAPSAICIN CREAM 0.035%","NDC":"59088024608"},{"Id":405963,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060104030","GenericName":"LIDOCAINE HCL GEL 5%","NDC":"59088024707"},{"Id":405964,"FormularyType":"OHP","DrugName":"DERMACINRX CRE PENETRAL","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"59088031008"},{"Id":405965,"FormularyType":"OHP","DrugName":"DERMACINRX CRE PENETRAL","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"59088031016"},{"Id":405966,"FormularyType":"OHP","DrugName":"LIDOTRAL GEL 5%","DosageForm":"GEL - Gel","Strength":"5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060104030","GenericName":"LIDOCAINE HCL GEL 5%","NDC":"59088032707"},{"Id":405967,"FormularyType":"OHP","DrugName":"UREA CRE 39.5%","DosageForm":"CREA - Cream","Strength":"39.5","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003723","GenericName":"UREA CREAM 39.5%","NDC":"59088069816"},{"Id":405968,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"59135000254"},{"Id":405969,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"59135000255"},{"Id":405970,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"59135000256"},{"Id":405971,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"59135000257"},{"Id":405972,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"59135000258"},{"Id":405973,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"59135000259"},{"Id":405974,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"59135000260"},{"Id":405975,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"59135000261"},{"Id":405976,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"59135000262"},{"Id":405977,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"59135000263"},{"Id":405978,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"59135000264"},{"Id":405979,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"59135000265"},{"Id":405980,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"59135000266"},{"Id":405981,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"59135000267"},{"Id":405982,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"59135000268"},{"Id":405983,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"59135000270"},{"Id":405984,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"59135000271"},{"Id":405985,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"59135000273"},{"Id":405986,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"59135000274"},{"Id":405987,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"59135000275"},{"Id":405988,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"59135000276"},{"Id":405989,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"59135000277"},{"Id":405990,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"59135000278"},{"Id":405991,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"59135000279"},{"Id":405992,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"59135000280"},{"Id":405993,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"59135000281"},{"Id":405994,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"59135000282"},{"Id":405995,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"59135000283"},{"Id":405996,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"59135000284"},{"Id":405997,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"59135000285"},{"Id":405998,"FormularyType":"OHP","DrugName":"VOYXACT INJ 400/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"400","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"IGA NEPHROPATHY (IGAN) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"5648055000E520","GenericName":"SIBEPRENLIMAB-SZSI SUBCUTANEOUS SOLN PREF SYRINGE 400 MG/2ML","NDC":"59148040075"},{"Id":405999,"FormularyType":"OHP","DrugName":"QVAR REDIHAL AER 40MCG","DosageForm":"AERB - Aerosol Breath Activated","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400010128120","GenericName":"BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 40 MCG/ACT","NDC":"59310030240"},{"Id":406000,"FormularyType":"OHP","DrugName":"QVAR REDIHA AER 80MCG","DosageForm":"AERB - Aerosol Breath Activated","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400010128140","GenericName":"BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 80 MCG/ACT","NDC":"59310030480"},{"Id":406001,"FormularyType":"OHP","DrugName":"RETACRIT INJ 2000UNIT","DosageForm":"SOLN - Solution","Strength":"2000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042010","GenericName":"EPOETIN ALFA-EPBX INJ 2000 UNIT/ML","NDC":"59353000201"},{"Id":406002,"FormularyType":"OHP","DrugName":"RETACRIT INJ 2000UNIT","DosageForm":"SOLN - Solution","Strength":"2000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042010","GenericName":"EPOETIN ALFA-EPBX INJ 2000 UNIT/ML","NDC":"59353000210"},{"Id":406003,"FormularyType":"OHP","DrugName":"RETACRIT INJ 3000UNIT","DosageForm":"SOLN - Solution","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042015","GenericName":"EPOETIN ALFA-EPBX INJ 3000 UNIT/ML","NDC":"59353000301"},{"Id":406004,"FormularyType":"OHP","DrugName":"RETACRIT INJ 3000UNIT","DosageForm":"SOLN - Solution","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042015","GenericName":"EPOETIN ALFA-EPBX INJ 3000 UNIT/ML","NDC":"59353000310"},{"Id":406005,"FormularyType":"OHP","DrugName":"RETACRIT INJ 4000UNIT","DosageForm":"SOLN - Solution","Strength":"4000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042020","GenericName":"EPOETIN ALFA-EPBX INJ 4000 UNIT/ML","NDC":"59353000401"},{"Id":406006,"FormularyType":"OHP","DrugName":"RETACRIT INJ 4000UNIT","DosageForm":"SOLN - Solution","Strength":"4000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042020","GenericName":"EPOETIN ALFA-EPBX INJ 4000 UNIT/ML","NDC":"59353000410"},{"Id":406007,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"59353001001"},{"Id":406008,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"59353001010"},{"Id":406009,"FormularyType":"OHP","DrugName":"RETACRIT INJ 20000UNI","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042050","GenericName":"EPOETIN ALFA-EPBX INJ 20000 UNIT/ML","NDC":"59353012001"},{"Id":406010,"FormularyType":"OHP","DrugName":"RETACRIT INJ 20000UNI","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042050","GenericName":"EPOETIN ALFA-EPBX INJ 20000 UNIT/ML","NDC":"59353012010"},{"Id":406011,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"59353022001"},{"Id":406012,"FormularyType":"OHP","DrugName":"RETACRIT INJ 10000UNT","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82401020042040","GenericName":"EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","NDC":"59353022010"},{"Id":406013,"FormularyType":"OHP","DrugName":"APRA ELX 160/5ML","DosageForm":"ELIX - Elixir","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001015","GenericName":"ACETAMINOPHEN ELIXIR 160 MG/5ML","NDC":"59390000235"},{"Id":406014,"FormularyType":"OHP","DrugName":"INSTACORT 5 CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"59390002217"},{"Id":406015,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"59390002601"},{"Id":406016,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"59390002617"},{"Id":406017,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"59390002662"},{"Id":406018,"FormularyType":"OHP","DrugName":"ACNE-CLEAR GEL 10%","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010004015","GenericName":"BENZOYL PEROXIDE GEL 10%","NDC":"59390003022"},{"Id":406019,"FormularyType":"OHP","DrugName":"APRA ELX 160/5ML","DosageForm":"ELIX - Elixir","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001015","GenericName":"ACETAMINOPHEN ELIXIR 160 MG/5ML","NDC":"59390004035"},{"Id":406020,"FormularyType":"OHP","DrugName":"APRA ELX 160/5ML","DosageForm":"ELIX - Elixir","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001015","GenericName":"ACETAMINOPHEN ELIXIR 160 MG/5ML","NDC":"59390004041"},{"Id":406021,"FormularyType":"OHP","DrugName":"APRA ELX 160/5ML","DosageForm":"ELIX - Elixir","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001015","GenericName":"ACETAMINOPHEN ELIXIR 160 MG/5ML","NDC":"59390004046"},{"Id":406022,"FormularyType":"OHP","DrugName":"APRA ELX 160/5ML","DosageForm":"ELIX - Elixir","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001015","GenericName":"ACETAMINOPHEN ELIXIR 160 MG/5ML","NDC":"59390004047"},{"Id":406023,"FormularyType":"OHP","DrugName":"ANTACID I SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"59390005045"},{"Id":406024,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS","DosageForm":"SUSP - Suspension","Strength":"7.75","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"59390005745"},{"Id":406025,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS","DosageForm":"SUSP - Suspension","Strength":"7.75","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"59390005746"},{"Id":406026,"FormularyType":"OHP","DrugName":"MICADERM CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"59390006717"},{"Id":406027,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"59390008017"},{"Id":406028,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS MAX","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"59390009617"},{"Id":406029,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"59390012541"},{"Id":406030,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"59390014005"},{"Id":406031,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"59390021702"},{"Id":406032,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"59390021705"},{"Id":406033,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"59390021710"},{"Id":406034,"FormularyType":"OHP","DrugName":"KLOXXADO SPR 8MG","DosageForm":"LIQD - Liquid","Strength":"8","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100930","GenericName":"NALOXONE HCL NASAL SPRAY 8 MG/0.1ML","NDC":"59467067901"},{"Id":406035,"FormularyType":"OHP","DrugName":"NEPHPLEX RX TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78136000000330","GenericName":"*B-COMPLEX W/ C-ZN & FOLIC ACID TAB 1 MG***","NDC":"59528031701"},{"Id":406036,"FormularyType":"OHP","DrugName":"NEPHRON FA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82992005200300","GenericName":"*FERROUS FUMARATE W/ FA-DSS-B COMPLEX-VIT C TAB***","NDC":"59528445601"},{"Id":406037,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59564025110"},{"Id":406038,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59564025130"},{"Id":406039,"FormularyType":"OHP","DrugName":"REVLIMID CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"59572040200"},{"Id":406040,"FormularyType":"OHP","DrugName":"REVLIMID CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"59572040228"},{"Id":406041,"FormularyType":"OHP","DrugName":"REVLIMID CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"59572040500"},{"Id":406042,"FormularyType":"OHP","DrugName":"REVLIMID CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"59572040528"},{"Id":406043,"FormularyType":"OHP","DrugName":"REVLIMID CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"59572041000"},{"Id":406044,"FormularyType":"OHP","DrugName":"REVLIMID CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"59572041028"},{"Id":406045,"FormularyType":"OHP","DrugName":"REVLIMID CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"59572041500"},{"Id":406046,"FormularyType":"OHP","DrugName":"REVLIMID CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"59572041521"},{"Id":406047,"FormularyType":"OHP","DrugName":"REVLIMID CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"59572042000"},{"Id":406048,"FormularyType":"OHP","DrugName":"REVLIMID CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"59572042021"},{"Id":406049,"FormularyType":"OHP","DrugName":"REVLIMID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"59572042500"},{"Id":406050,"FormularyType":"OHP","DrugName":"REVLIMID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"O","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"59572042521"},{"Id":406051,"FormularyType":"OHP","DrugName":"IDHIFA TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535030200320","GenericName":"ENASIDENIB MESYLATE TAB 50 MG (BASE EQUIVALENT)","NDC":"59572070530"},{"Id":406052,"FormularyType":"OHP","DrugName":"IDHIFA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535030200340","GenericName":"ENASIDENIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"59572071030"},{"Id":406053,"FormularyType":"OHP","DrugName":"INREBIC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537520200120","GenericName":"FEDRATINIB HCL CAP 100 MG","NDC":"59572072012"},{"Id":406054,"FormularyType":"OHP","DrugName":"ONUREG TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300003000320","GenericName":"AZACITIDINE TAB 200 MG","NDC":"59572073007"},{"Id":406055,"FormularyType":"OHP","DrugName":"ONUREG TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300003000330","GenericName":"AZACITIDINE TAB 300 MG","NDC":"59572074007"},{"Id":406056,"FormularyType":"OHP","DrugName":"ORALAIR SUB 300 IR","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20109905200730","GenericName":"*GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)*","NDC":"59617001502"},{"Id":406057,"FormularyType":"OHP","DrugName":"ORALAIR SUB 300 IR","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20109905200730","GenericName":"*GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)*","NDC":"59617001503"},{"Id":406058,"FormularyType":"OHP","DrugName":"ORALAIR ADLT SUB 300 IR","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ALLERGENIC EXTRACTS/BIOLOGICALS MISC","DrugSubClass":"ALLERGENIC EXTRACTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"20109905200730","GenericName":"*GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)*","NDC":"59617001601"},{"Id":406059,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"59651000101"},{"Id":406060,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"59651000130"},{"Id":406061,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"59651000205"},{"Id":406062,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"59651000290"},{"Id":406063,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"59651000299"},{"Id":406064,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"59651000305"},{"Id":406065,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"59651000330"},{"Id":406066,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"59651000715"},{"Id":406067,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"59651000815"},{"Id":406068,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"59651000823"},{"Id":406069,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"59651000830"},{"Id":406070,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"59651000960"},{"Id":406071,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"59651001060"},{"Id":406072,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"59651001602"},{"Id":406073,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG ER","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"59651001818"},{"Id":406074,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG ER","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"59651001890"},{"Id":406075,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 750MG","DosageForm":"TBCR - Tablet ER","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000460","GenericName":"NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC)","NDC":"59651001918"},{"Id":406076,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 750MG","DosageForm":"TBCR - Tablet ER","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000460","GenericName":"NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC)","NDC":"59651001990"},{"Id":406077,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"59651002018"},{"Id":406078,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"59651002090"},{"Id":406079,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"59651002130"},{"Id":406080,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"59651002190"},{"Id":406081,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"59651002601"},{"Id":406082,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"59651002655"},{"Id":406083,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"59651002675"},{"Id":406084,"FormularyType":"OHP","DrugName":"LO-ZUMANDIMI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"59651002928"},{"Id":406085,"FormularyType":"OHP","DrugName":"LO-ZUMANDIMI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"59651002988"},{"Id":406086,"FormularyType":"OHP","DrugName":"ZUMANDIMINE TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"59651003028"},{"Id":406087,"FormularyType":"OHP","DrugName":"ZUMANDIMINE TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"59651003085"},{"Id":406088,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59651003212"},{"Id":406089,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59651003247"},{"Id":406090,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"59651005205"},{"Id":406091,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"59651005230"},{"Id":406092,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"59651005290"},{"Id":406093,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"59651008314"},{"Id":406094,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"59651008460"},{"Id":406095,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"59651008560"},{"Id":406096,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"59651008630"},{"Id":406097,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100320","GenericName":"SEVELAMER HCL TAB 400 MG","NDC":"59651008736"},{"Id":406098,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100340","GenericName":"SEVELAMER HCL TAB 800 MG","NDC":"59651008818"},{"Id":406099,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"59651010406"},{"Id":406100,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"59651010469"},{"Id":406101,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"59651010506"},{"Id":406102,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"59651010569"},{"Id":406103,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"59651011330"},{"Id":406104,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"59651011430"},{"Id":406105,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"59651011860"},{"Id":406106,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"59651011960"},{"Id":406107,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"59651012060"},{"Id":406108,"FormularyType":"OHP","DrugName":"EMZAHH TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"59651013628"},{"Id":406109,"FormularyType":"OHP","DrugName":"EMZAHH TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"59651013688"},{"Id":406110,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"59651015201"},{"Id":406111,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"59651015301"},{"Id":406112,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 100-150","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300308","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG","NDC":"59651016530"},{"Id":406113,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 133-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300312","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 133-200 MG","NDC":"59651016630"},{"Id":406114,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 167-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300316","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG","NDC":"59651016730"},{"Id":406115,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"59651018030"},{"Id":406116,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"59651018201"},{"Id":406117,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"59651018325"},{"Id":406118,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"59651018330"},{"Id":406119,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"59651018425"},{"Id":406120,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"59651018430"},{"Id":406121,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000110","GenericName":"POMALIDOMIDE CAP 1 MG","NDC":"59651019421"},{"Id":406122,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000115","GenericName":"POMALIDOMIDE CAP 2 MG","NDC":"59651019521"},{"Id":406123,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000120","GenericName":"POMALIDOMIDE CAP 3 MG","NDC":"59651019621"},{"Id":406124,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000125","GenericName":"POMALIDOMIDE CAP 4 MG","NDC":"59651019721"},{"Id":406125,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"59651020101"},{"Id":406126,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"59651020201"},{"Id":406127,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"59651020301"},{"Id":406128,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"59651020460"},{"Id":406129,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"59651020508"},{"Id":406130,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"59651021430"},{"Id":406131,"FormularyType":"OHP","DrugName":"FENOFIBRIC CAP 45MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200006006520","GenericName":"CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV)","NDC":"59651021690"},{"Id":406132,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"59651022401"},{"Id":406133,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100320","GenericName":"PILOCARPINE HCL TAB 7.5 MG","NDC":"59651022501"},{"Id":406134,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"59651023201"},{"Id":406135,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"59651023299"},{"Id":406136,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"59651023301"},{"Id":406137,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"59651023305"},{"Id":406138,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"59651023401"},{"Id":406139,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"59651023405"},{"Id":406140,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"59651023630"},{"Id":406141,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"59651023690"},{"Id":406142,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"59651023827"},{"Id":406143,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"59651023890"},{"Id":406144,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"59651023990"},{"Id":406145,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"59651024090"},{"Id":406146,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"59651024130"},{"Id":406147,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"59651024601"},{"Id":406148,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"59651024701"},{"Id":406149,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"59651024801"},{"Id":406150,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100310","GenericName":"DESMOPRESSIN ACETATE TAB 0.1 MG","NDC":"59651024901"},{"Id":406151,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100320","GenericName":"DESMOPRESSIN ACETATE TAB 0.2 MG","NDC":"59651025001"},{"Id":406152,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"59651025101"},{"Id":406153,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"59651025201"},{"Id":406154,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000320","GenericName":"PROPAFENONE HCL TAB 150 MG","NDC":"59651025601"},{"Id":406155,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000325","GenericName":"PROPAFENONE HCL TAB 225 MG","NDC":"59651025701"},{"Id":406156,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000330","GenericName":"PROPAFENONE HCL TAB 300 MG","NDC":"59651025801"},{"Id":406157,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"59651027101"},{"Id":406158,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"59651027199"},{"Id":406159,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"59651027201"},{"Id":406160,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"59651027299"},{"Id":406161,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"59651027301"},{"Id":406162,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"59651027325"},{"Id":406163,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"59651027530"},{"Id":406164,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"59651027590"},{"Id":406165,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"59651028501"},{"Id":406166,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"59651028599"},{"Id":406167,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"59651028601"},{"Id":406168,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"59651028605"},{"Id":406169,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000310","GenericName":"ZAFIRLUKAST TAB 10 MG","NDC":"59651029160"},{"Id":406170,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000320","GenericName":"ZAFIRLUKAST TAB 20 MG","NDC":"59651029260"},{"Id":406171,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007530","GenericName":"NIFEDIPINE TAB ER 24HR 30 MG","NDC":"59651029501"},{"Id":406172,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007540","GenericName":"NIFEDIPINE TAB ER 24HR 60 MG","NDC":"59651029601"},{"Id":406173,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007550","GenericName":"NIFEDIPINE TAB ER 24HR 90 MG","NDC":"59651029701"},{"Id":406174,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100310","GenericName":"TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"59651029960"},{"Id":406175,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"59651030030"},{"Id":406176,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"59651030090"},{"Id":406177,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000307","GenericName":"CHLORZOXAZONE TAB 375 MG","NDC":"59651030501"},{"Id":406178,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"59651030601"},{"Id":406179,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"59651030605"},{"Id":406180,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000320","GenericName":"CHLORZOXAZONE TAB 750 MG","NDC":"59651030701"},{"Id":406181,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"59651032905"},{"Id":406182,"FormularyType":"OHP","DrugName":"MONTELUKAST GRA 4MG","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050103020","GenericName":"MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","NDC":"59651032930"},{"Id":406183,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000105","GenericName":"FLUCYTOSINE CAP 250 MG","NDC":"59651033101"},{"Id":406184,"FormularyType":"OHP","DrugName":"FLUCYTOSINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000020000110","GenericName":"FLUCYTOSINE CAP 500 MG","NDC":"59651033201"},{"Id":406185,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"59651034001"},{"Id":406186,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"59651034005"},{"Id":406187,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"59651034101"},{"Id":406188,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"59651034105"},{"Id":406189,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"59651034228"},{"Id":406190,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"59651034328"},{"Id":406191,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"59651034428"},{"Id":406192,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"59651034521"},{"Id":406193,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"59651034621"},{"Id":406194,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"59651034721"},{"Id":406195,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"59651034830"},{"Id":406196,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"59651034930"},{"Id":406197,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"59651036001"},{"Id":406198,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"59651036005"},{"Id":406199,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"59651036101"},{"Id":406200,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"59651036105"},{"Id":406201,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"59651036201"},{"Id":406202,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"59651036205"},{"Id":406203,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"59651036650"},{"Id":406204,"FormularyType":"OHP","DrugName":"VIGABATRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085000320","GenericName":"VIGABATRIN TAB 500 MG","NDC":"59651036701"},{"Id":406205,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"59651037801"},{"Id":406206,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"59651037901"},{"Id":406207,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"59651038001"},{"Id":406208,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"59651039401"},{"Id":406209,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"59651039405"},{"Id":406210,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"59651039499"},{"Id":406211,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"59651039501"},{"Id":406212,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"59651039505"},{"Id":406213,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"59651039599"},{"Id":406214,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"59651039708"},{"Id":406215,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"59651040112"},{"Id":406216,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"59651041030"},{"Id":406217,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"59651041130"},{"Id":406218,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"59651041230"},{"Id":406219,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"59651041350"},{"Id":406220,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"59651041401"},{"Id":406221,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"59651041501"},{"Id":406222,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"59651041756"},{"Id":406223,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"59651041856"},{"Id":406224,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"59651042101"},{"Id":406225,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59651042601"},{"Id":406226,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59651042605"},{"Id":406227,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59651042699"},{"Id":406228,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"59651042701"},{"Id":406229,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"59651042705"},{"Id":406230,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"59651042801"},{"Id":406231,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"59651043701"},{"Id":406232,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"59651043799"},{"Id":406233,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"59651043801"},{"Id":406234,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"59651043899"},{"Id":406235,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"59651043908"},{"Id":406236,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"59651043918"},{"Id":406237,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"59651044401"},{"Id":406238,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"59651045153"},{"Id":406239,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006820","GenericName":"TOPIRAMATE SPRINKLE CAP 15 MG","NDC":"59651045260"},{"Id":406240,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 25MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006830","GenericName":"TOPIRAMATE SPRINKLE CAP 25 MG","NDC":"59651045360"},{"Id":406241,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"59651045501"},{"Id":406242,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"59651045530"},{"Id":406243,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"59651045601"},{"Id":406244,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"59651045701"},{"Id":406245,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"59651045705"},{"Id":406246,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"59651045801"},{"Id":406247,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"59651045805"},{"Id":406248,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"59651046428"},{"Id":406249,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"59651046528"},{"Id":406250,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"59651046628"},{"Id":406251,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"59651046728"},{"Id":406252,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"59651048401"},{"Id":406253,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"59651048499"},{"Id":406254,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"59651048501"},{"Id":406255,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"59651048601"},{"Id":406256,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"59651048699"},{"Id":406257,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"59651048701"},{"Id":406258,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"59651048705"},{"Id":406259,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"59651048801"},{"Id":406260,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"59651048805"},{"Id":406261,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"59651048901"},{"Id":406262,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"59651049347"},{"Id":406263,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"59651049430"},{"Id":406264,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"59651049530"},{"Id":406265,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"59651049901"},{"Id":406266,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"59651049905"},{"Id":406267,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"59651050001"},{"Id":406268,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"59651050005"},{"Id":406269,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"59651050099"},{"Id":406270,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"59651050101"},{"Id":406271,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"59651050105"},{"Id":406272,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"59651050199"},{"Id":406273,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"59651050501"},{"Id":406274,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"59651050530"},{"Id":406275,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"59651051630"},{"Id":406276,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"59651053901"},{"Id":406277,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"59651053905"},{"Id":406278,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"59651054001"},{"Id":406279,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"59651054005"},{"Id":406280,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 120MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007540","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG","NDC":"59651054101"},{"Id":406281,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"59651054260"},{"Id":406282,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"59651054360"},{"Id":406283,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"59651054460"},{"Id":406284,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"59651054530"},{"Id":406285,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"59651054630"},{"Id":406286,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"59651054730"},{"Id":406287,"FormularyType":"OHP","DrugName":"AMPICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020200110","GenericName":"AMPICILLIN CAP 500 MG","NDC":"59651055101"},{"Id":406288,"FormularyType":"OHP","DrugName":"AMPICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020200110","GenericName":"AMPICILLIN CAP 500 MG","NDC":"59651055105"},{"Id":406289,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"59651056130"},{"Id":406290,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"59651056230"},{"Id":406291,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"59651056290"},{"Id":406292,"FormularyType":"OHP","DrugName":"DICLOXACILL CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300020100110","GenericName":"DICLOXACILLIN SODIUM CAP 250 MG","NDC":"59651056501"},{"Id":406293,"FormularyType":"OHP","DrugName":"DICLOXACILL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300020100115","GenericName":"DICLOXACILLIN SODIUM CAP 500 MG","NDC":"59651056601"},{"Id":406294,"FormularyType":"OHP","DrugName":"SAPROPTERIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565100320","GenericName":"SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG","NDC":"59651057408"},{"Id":406295,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"59651057590"},{"Id":406296,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"59651057690"},{"Id":406297,"FormularyType":"OHP","DrugName":"PAZOPANIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533042100320","GenericName":"PAZOPANIB HCL TAB 200 MG (BASE EQUIV)","NDC":"59651058208"},{"Id":406298,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"59651058505"},{"Id":406299,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"59651058530"},{"Id":406300,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"59651058901"},{"Id":406301,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"59651059660"},{"Id":406302,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"59651059760"},{"Id":406303,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"59651060690"},{"Id":406304,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"59651060699"},{"Id":406305,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"59651060790"},{"Id":406306,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"59651060799"},{"Id":406307,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"59651060890"},{"Id":406308,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"59651060899"},{"Id":406309,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"59651060990"},{"Id":406310,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"59651060999"},{"Id":406311,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"59651062108"},{"Id":406312,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"59651062208"},{"Id":406313,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"59651062401"},{"Id":406314,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"59651062405"},{"Id":406315,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"59651063103"},{"Id":406316,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"59651063110"},{"Id":406317,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"59651063203"},{"Id":406318,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"59651063210"},{"Id":406319,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"59651063403"},{"Id":406320,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"59651063410"},{"Id":406321,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"59651063603"},{"Id":406322,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"59651063610"},{"Id":406323,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"59651063801"},{"Id":406324,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"59651063805"},{"Id":406325,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"59651064626"},{"Id":406326,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"59651065103"},{"Id":406327,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"59651065700"},{"Id":406328,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"59651065800"},{"Id":406329,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"59651065804"},{"Id":406330,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"59651065825"},{"Id":406331,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"59651065900"},{"Id":406332,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"59651069101"},{"Id":406333,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"59651069105"},{"Id":406334,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"59651070150"},{"Id":406335,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"59651071901"},{"Id":406336,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"59651071999"},{"Id":406337,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"59651072001"},{"Id":406338,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"59651072099"},{"Id":406339,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"59651072201"},{"Id":406340,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"59651072299"},{"Id":406341,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"59651072301"},{"Id":406342,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"59651072399"},{"Id":406343,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"59651072401"},{"Id":406344,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"59651072405"},{"Id":406345,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"59651073214"},{"Id":406346,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"59651073230"},{"Id":406347,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"59651073246"},{"Id":406348,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"59651073260"},{"Id":406349,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"59651075301"},{"Id":406350,"FormularyType":"OHP","DrugName":"METRONIDAZOL CRE 0.75%","DosageForm":"CREA - Cream","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040003710","GenericName":"METRONIDAZOLE CREAM 0.75%","NDC":"59651077046"},{"Id":406351,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"59651077301"},{"Id":406352,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"59651077401"},{"Id":406353,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120310","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 80 MG","NDC":"59651077501"},{"Id":406354,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120315","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 120 MG","NDC":"59651077601"},{"Id":406355,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120320","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 160 MG","NDC":"59651077701"},{"Id":406356,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 2.5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007505","GenericName":"GLIPIZIDE TAB ER 24HR 2.5 MG","NDC":"59651078030"},{"Id":406357,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"59651078101"},{"Id":406358,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"59651078105"},{"Id":406359,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"59651078201"},{"Id":406360,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"59651078205"},{"Id":406361,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"59651079501"},{"Id":406362,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"59651079601"},{"Id":406363,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"59651079699"},{"Id":406364,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"59651079701"},{"Id":406365,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"59651079799"},{"Id":406366,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"59651079801"},{"Id":406367,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"59651079805"},{"Id":406368,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"59651080128"},{"Id":406369,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"59651080701"},{"Id":406370,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"59651080801"},{"Id":406371,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"59651080899"},{"Id":406372,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"59651082301"},{"Id":406373,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000310","GenericName":"CIMETIDINE TAB 300 MG","NDC":"59651082401"},{"Id":406374,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000315","GenericName":"CIMETIDINE TAB 400 MG","NDC":"59651082501"},{"Id":406375,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000320","GenericName":"CIMETIDINE TAB 800 MG","NDC":"59651082601"},{"Id":406376,"FormularyType":"OHP","DrugName":"TRANEX ACID TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"HEMOSTATICS","DrugSubClass":"HEMOSTATICS - SYSTEMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"84100040000320","GenericName":"TRANEXAMIC ACID TAB 650 MG","NDC":"59651083930"},{"Id":406377,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"59651084001"},{"Id":406378,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"59651084101"},{"Id":406379,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"59651084201"},{"Id":406380,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"59651084260"},{"Id":406381,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"59651084299"},{"Id":406382,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"59651084301"},{"Id":406383,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"59651084305"},{"Id":406384,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"59651084360"},{"Id":406385,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"59651084399"},{"Id":406386,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"59651085401"},{"Id":406387,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"59651085405"},{"Id":406388,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"59651085499"},{"Id":406389,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"59651085501"},{"Id":406390,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"59651085505"},{"Id":406391,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"59651085601"},{"Id":406392,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"59651085605"},{"Id":406393,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"59651085699"},{"Id":406394,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"59651086601"},{"Id":406395,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"59651087350"},{"Id":406396,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"59651088901"},{"Id":406397,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"59651088905"},{"Id":406398,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"59651089201"},{"Id":406399,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"59651089299"},{"Id":406400,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"59651089301"},{"Id":406401,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"59651089399"},{"Id":406402,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"59651089401"},{"Id":406403,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"59651089499"},{"Id":406404,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"59651089501"},{"Id":406405,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"59651089599"},{"Id":406406,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"59651090501"},{"Id":406407,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"59651090601"},{"Id":406408,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"59651090714"},{"Id":406409,"FormularyType":"OHP","DrugName":"NYSTATIN CRE 100000","DosageForm":"CREA - Cream","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080003710","GenericName":"NYSTATIN CREAM 100000 UNIT/GM","NDC":"59651090730"},{"Id":406410,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% VISC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"59651094301"},{"Id":406411,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"59651097360"},{"Id":406412,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"59651097460"},{"Id":406413,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"59651097560"},{"Id":406414,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"59651097701"},{"Id":406415,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"59651097705"},{"Id":406416,"FormularyType":"OHP","DrugName":"BALVERSA TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532225000320","GenericName":"ERDAFITINIB TAB 3 MG","NDC":"59676003056"},{"Id":406417,"FormularyType":"OHP","DrugName":"BALVERSA TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532225000320","GenericName":"ERDAFITINIB TAB 3 MG","NDC":"59676003084"},{"Id":406418,"FormularyType":"OHP","DrugName":"BALVERSA TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532225000325","GenericName":"ERDAFITINIB TAB 4 MG","NDC":"59676004028"},{"Id":406419,"FormularyType":"OHP","DrugName":"BALVERSA TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532225000325","GenericName":"ERDAFITINIB TAB 4 MG","NDC":"59676004056"},{"Id":406420,"FormularyType":"OHP","DrugName":"BALVERSA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532225000330","GenericName":"ERDAFITINIB TAB 5 MG","NDC":"59676005028"},{"Id":406421,"FormularyType":"OHP","DrugName":"EDURANT PED TAB 2.5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109080107320","GenericName":"RILPIVIRINE HCL TAB FOR ORAL SUSP 2.5 MG (BASE EQUIVALENT)","NDC":"59676028001"},{"Id":406422,"FormularyType":"OHP","DrugName":"EDURANT PED TAB 2.5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109080107320","GenericName":"RILPIVIRINE HCL TAB FOR ORAL SUSP 2.5 MG (BASE EQUIVALENT)","NDC":"59676028090"},{"Id":406423,"FormularyType":"OHP","DrugName":"PREZISTA TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000305","GenericName":"DARUNAVIR TAB 75 MG","NDC":"59676056301"},{"Id":406424,"FormularyType":"OHP","DrugName":"PREZISTA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000310","GenericName":"DARUNAVIR TAB 150 MG","NDC":"59676056401"},{"Id":406425,"FormularyType":"OHP","DrugName":"PREZISTA SUS 100MG/ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520001820","GenericName":"DARUNAVIR ORAL SUSP 100 MG/ML","NDC":"59676056501"},{"Id":406426,"FormularyType":"OHP","DrugName":"INTELENCE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000310","GenericName":"ETRAVIRINE TAB 25 MG","NDC":"59676057201"},{"Id":406427,"FormularyType":"OHP","DrugName":"PREZCOBIX TAB 800-150","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902270320","GenericName":"DARUNAVIR-COBICISTAT TAB 800-150 MG","NDC":"59676057530"},{"Id":406428,"FormularyType":"OHP","DrugName":"PREZCOBIX TAB 675/150","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902270315","GenericName":"DARUNAVIR-COBICISTAT TAB 675-150 MG","NDC":"59676057830"},{"Id":406429,"FormularyType":"OHP","DrugName":"ERLEADA TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402410000320","GenericName":"APALUTAMIDE TAB 60 MG","NDC":"59676060012"},{"Id":406430,"FormularyType":"OHP","DrugName":"ERLEADA TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402410000360","GenericName":"APALUTAMIDE TAB 240 MG","NDC":"59676060430"},{"Id":406431,"FormularyType":"OHP","DrugName":"SIRTURO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000015100320","GenericName":"BEDAQUILINE FUMARATE TAB 100 MG (BASE EQUIV)","NDC":"59676070101"},{"Id":406432,"FormularyType":"OHP","DrugName":"SIRTURO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000015100310","GenericName":"BEDAQUILINE FUMARATE TAB 20 MG (BASE EQUIV)","NDC":"59676070260"},{"Id":406433,"FormularyType":"OHP","DrugName":"SYMTUZA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109904200320","GenericName":"DARUNAVIR-COBIC-EMTRICITAB-TENOFOV AF TAB 800-150-200-10 MG","NDC":"59676080030"},{"Id":406434,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"59726000220"},{"Id":406435,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"59726016060"},{"Id":406436,"FormularyType":"OHP","DrugName":"WAL-PROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"59726024020"},{"Id":406437,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210003000B705","GenericName":"METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","NDC":"59746000103"},{"Id":406438,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"59746000106"},{"Id":406439,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000315","GenericName":"METHYLPREDNISOLONE TAB 8 MG","NDC":"59746000204"},{"Id":406440,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000320","GenericName":"METHYLPREDNISOLONE TAB 16 MG","NDC":"59746000314"},{"Id":406441,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000330","GenericName":"METHYLPREDNISOLONE TAB 32 MG","NDC":"59746001504"},{"Id":406442,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"59746011306"},{"Id":406443,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"59746011506"},{"Id":406444,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"59746012106"},{"Id":406445,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"59746012110"},{"Id":406446,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"59746012206"},{"Id":406447,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"59746012210"},{"Id":406448,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"59746017106"},{"Id":406449,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"59746017110"},{"Id":406450,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"59746017206"},{"Id":406451,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"59746017210"},{"Id":406452,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"59746017306"},{"Id":406453,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"59746017310"},{"Id":406454,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"59746017506"},{"Id":406455,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"59746017509"},{"Id":406456,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"59746017706"},{"Id":406457,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"59746017710"},{"Id":406458,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"59746021106"},{"Id":406459,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"59746021110"},{"Id":406460,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59746021601"},{"Id":406461,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59746021605"},{"Id":406462,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59746021606"},{"Id":406463,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"59746021609"},{"Id":406464,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"59746021701"},{"Id":406465,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"59746021706"},{"Id":406466,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"59746021801"},{"Id":406467,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"59746021806"},{"Id":406468,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"59746032430"},{"Id":406469,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"59746032437"},{"Id":406470,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"59746032490"},{"Id":406471,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"59746032530"},{"Id":406472,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"59746032537"},{"Id":406473,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"59746032590"},{"Id":406474,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"59746033310"},{"Id":406475,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"59746033390"},{"Id":406476,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"59746033410"},{"Id":406477,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"59746033430"},{"Id":406478,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"59746033490"},{"Id":406479,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"59746033510"},{"Id":406480,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"59746033530"},{"Id":406481,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"59746033590"},{"Id":406482,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"59746038306"},{"Id":406483,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"59746038309"},{"Id":406484,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"59746038310"},{"Id":406485,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"59746038406"},{"Id":406486,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"59746038409"},{"Id":406487,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"59746038410"},{"Id":406488,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"59746038506"},{"Id":406489,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"59746038509"},{"Id":406490,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"59746038510"},{"Id":406491,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"59746038606"},{"Id":406492,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"59746038609"},{"Id":406493,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"59746038610"},{"Id":406494,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"59746046330"},{"Id":406495,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"59746046530"},{"Id":406496,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"59746046590"},{"Id":406497,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"59746046630"},{"Id":406498,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"59746046690"},{"Id":406499,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"59746076201"},{"Id":406500,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"59746076206"},{"Id":406501,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"59746078201"},{"Id":406502,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"59746078301"},{"Id":406503,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"59746078901"},{"Id":406504,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"59746079001"},{"Id":406505,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"59746079101"},{"Id":406506,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"59746079801"},{"Id":406507,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"59746079901"},{"Id":406508,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"59746080001"},{"Id":406509,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"59746080170"},{"Id":406510,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"59746080230"},{"Id":406511,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"59746080290"},{"Id":406512,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"59762003303"},{"Id":406513,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"59762004701"},{"Id":406514,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"59762004702"},{"Id":406515,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"59762004801"},{"Id":406516,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"59762004802"},{"Id":406517,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000315","GenericName":"METHYLPREDNISOLONE TAB 8 MG","NDC":"59762004901"},{"Id":406518,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000320","GenericName":"METHYLPREDNISOLONE TAB 16 MG","NDC":"59762005001"},{"Id":406519,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000330","GenericName":"METHYLPREDNISOLONE TAB 32 MG","NDC":"59762005101"},{"Id":406520,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200305","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 2.5 MG","NDC":"59762005501"},{"Id":406521,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200305","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 2.5 MG","NDC":"59762005502"},{"Id":406522,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200315","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 10 MG","NDC":"59762005601"},{"Id":406523,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200315","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 10 MG","NDC":"59762005602"},{"Id":406524,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200310","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 5 MG","NDC":"59762005801"},{"Id":406525,"FormularyType":"OHP","DrugName":"MEDROXYPR AC TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000020200310","GenericName":"MEDROXYPROGESTERONE ACETATE TAB 5 MG","NDC":"59762005802"},{"Id":406526,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"59762007301"},{"Id":406527,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"59762007401"},{"Id":406528,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"59762007501"},{"Id":406529,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG DR","DosageForm":"TBEC - Tablet DR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000610","GenericName":"SULFASALAZINE TAB DELAYED RELEASE 500 MG","NDC":"59762010405"},{"Id":406530,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG DR","DosageForm":"TBEC - Tablet DR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000610","GenericName":"SULFASALAZINE TAB DELAYED RELEASE 500 MG","NDC":"59762010406"},{"Id":406531,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"59762013100"},{"Id":406532,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"59762013102"},{"Id":406533,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"59762013104"},{"Id":406534,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"59762013105"},{"Id":406535,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"59762013106"},{"Id":406536,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"59762013108"},{"Id":406537,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"59762017001"},{"Id":406538,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"59762017006"},{"Id":406539,"FormularyType":"OHP","DrugName":"COLESTIPOL GRA 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020103010","GenericName":"COLESTIPOL HCL GRANULE PACKETS 5 GM","NDC":"59762026001"},{"Id":406540,"FormularyType":"OHP","DrugName":"COLESTIPOL GRA 5GM","DosageForm":"PACK - Packet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020103010","GenericName":"COLESTIPOL HCL GRANULE PACKETS 5 GM","NDC":"59762026002"},{"Id":406541,"FormularyType":"OHP","DrugName":"COLESTIPOL GRA 5GM","DosageForm":"GRAN - Granules","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020102705","GenericName":"COLESTIPOL HCL GRANULES 5 GM","NDC":"59762026003"},{"Id":406542,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"59762033302"},{"Id":406543,"FormularyType":"OHP","DrugName":"DISOPYRAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010100105","GenericName":"DISOPYRAMIDE PHOSPHATE CAP 100 MG","NDC":"59762038601"},{"Id":406544,"FormularyType":"OHP","DrugName":"DISOPYRAMIDE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010100110","GenericName":"DISOPYRAMIDE PHOSPHATE CAP 150 MG","NDC":"59762040001"},{"Id":406545,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"59762040101"},{"Id":406546,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"59762040105"},{"Id":406547,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"59762040504"},{"Id":406548,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"59762040601"},{"Id":406549,"FormularyType":"OHP","DrugName":"COLESTIPOL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020100320","GenericName":"COLESTIPOL HCL TAB 1 GM","NDC":"59762045001"},{"Id":406550,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"59762048901"},{"Id":406551,"FormularyType":"OHP","DrugName":"PHENYTOIN SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030001810","GenericName":"PHENYTOIN SUSP 125 MG/5ML","NDC":"59762053102"},{"Id":406552,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"59762080002"},{"Id":406553,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"59762080006"},{"Id":406554,"FormularyType":"OHP","DrugName":"VORICONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407080001920","GenericName":"VORICONAZOLE FOR SUSP 40 MG/ML","NDC":"59762093503"},{"Id":406555,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000310","GenericName":"SIROLIMUS TAB 0.5 MG","NDC":"59762100101"},{"Id":406556,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"59762100201"},{"Id":406557,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000330","GenericName":"SIROLIMUS TAB 2 MG","NDC":"59762100301"},{"Id":406558,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"59762100501"},{"Id":406559,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"59762106101"},{"Id":406560,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"59762110702"},{"Id":406561,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"59762110703"},{"Id":406562,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"59762110801"},{"Id":406563,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"59762110802"},{"Id":406564,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"59762120504"},{"Id":406565,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"59762120506"},{"Id":406566,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"59762120601"},{"Id":406567,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"59762120701"},{"Id":406568,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"59762120801"},{"Id":406569,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"59762130701"},{"Id":406570,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"59762130702"},{"Id":406571,"FormularyType":"OHP","DrugName":"LINEZOLID SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040001920","GenericName":"LINEZOLID FOR SUSP 100 MG/5ML","NDC":"59762130804"},{"Id":406572,"FormularyType":"OHP","DrugName":"RIFABUTIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000075000120","GenericName":"RIFABUTIN CAP 150 MG","NDC":"59762135001"},{"Id":406573,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"59762138807"},{"Id":406574,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"59762139007"},{"Id":406575,"FormularyType":"OHP","DrugName":"PREGABALIN SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057002020","GenericName":"PREGABALIN SOLN 20 MG/ML","NDC":"59762157601"},{"Id":406576,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"59762201001"},{"Id":406577,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"59762201003"},{"Id":406578,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"59762201009"},{"Id":406579,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"59762213501"},{"Id":406580,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"59762213509"},{"Id":406581,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"59762224203"},{"Id":406582,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"59762224209"},{"Id":406583,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010002005","GenericName":"ETHOSUXIMIDE SOLN 250 MG/5ML","NDC":"59762235007"},{"Id":406584,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"59762242007"},{"Id":406585,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"59762248007"},{"Id":406586,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"59762285801"},{"Id":406587,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"59762330401"},{"Id":406588,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"59762330403"},{"Id":406589,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"59762332801"},{"Id":406590,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000305","GenericName":"TRIAZOLAM TAB 0.125 MG","NDC":"59762371709"},{"Id":406591,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000310","GenericName":"TRIAZOLAM TAB 0.25 MG","NDC":"59762371803"},{"Id":406592,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000310","GenericName":"TRIAZOLAM TAB 0.25 MG","NDC":"59762371809"},{"Id":406593,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"59762374301"},{"Id":406594,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"59762374302"},{"Id":406595,"FormularyType":"OHP","DrugName":"CLINDAMYCIN LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104105","GenericName":"CLINDAMYCIN PHOSPHATE LOTION 1%","NDC":"59762374401"},{"Id":406596,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210003000B705","GenericName":"METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","NDC":"59762444002"},{"Id":406597,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"59762444003"},{"Id":406598,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"59762492101"},{"Id":406599,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"59762500005"},{"Id":406600,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"59762500006"},{"Id":406601,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000310","GenericName":"MISOPROSTOL TAB 100 MCG","NDC":"59762500701"},{"Id":406602,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000310","GenericName":"MISOPROSTOL TAB 100 MCG","NDC":"59762500702"},{"Id":406603,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"59762500801"},{"Id":406604,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"59762500802"},{"Id":406605,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CRE 2% VAG","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100018103720","GenericName":"CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2%","NDC":"59762500901"},{"Id":406606,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"59762501002"},{"Id":406607,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 10MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001910","GenericName":"FLUCONAZOLE FOR SUSP 10 MG/ML","NDC":"59762502901"},{"Id":406608,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001940","GenericName":"FLUCONAZOLE FOR SUSP 40 MG/ML","NDC":"59762503001"},{"Id":406609,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"59762505007"},{"Id":406610,"FormularyType":"OHP","DrugName":"HEARTBURN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"59779002272"},{"Id":406611,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"59779005027"},{"Id":406612,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"59779005060"},{"Id":406613,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"59779006200"},{"Id":406614,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"59779008001"},{"Id":406615,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"59779008002"},{"Id":406616,"FormularyType":"OHP","DrugName":"CORTISONE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"59779009902"},{"Id":406617,"FormularyType":"OHP","DrugName":"CORTISONE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"59779009903"},{"Id":406618,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"59779012626"},{"Id":406619,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"59779014139"},{"Id":406620,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"59779014175"},{"Id":406621,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779016626"},{"Id":406622,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779016634"},{"Id":406623,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"59779018224"},{"Id":406624,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"59779019463"},{"Id":406625,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"59779019471"},{"Id":406626,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"59779019478"},{"Id":406627,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"59779019703"},{"Id":406628,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"59779021701"},{"Id":406629,"FormularyType":"OHP","DrugName":"CORTISONE OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"59779025503"},{"Id":406630,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"59779026326"},{"Id":406631,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"59779027408"},{"Id":406632,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"59779027468"},{"Id":406633,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"59779030501"},{"Id":406634,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"59779030502"},{"Id":406635,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"59779030601"},{"Id":406636,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"59779030602"},{"Id":406637,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"59779030603"},{"Id":406638,"FormularyType":"OHP","DrugName":"CVS PURELAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"59779030604"},{"Id":406639,"FormularyType":"OHP","DrugName":"CVS PURELAX PAK","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"59779030652"},{"Id":406640,"FormularyType":"OHP","DrugName":"CVS PURELAX PAK","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"59779030660"},{"Id":406641,"FormularyType":"OHP","DrugName":"CVS IBUPROF DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"59779031310"},{"Id":406642,"FormularyType":"OHP","DrugName":"CVS ALLERGY DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"59779033001"},{"Id":406643,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"59779033408"},{"Id":406644,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779034404"},{"Id":406645,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779034411"},{"Id":406646,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"59779036751"},{"Id":406647,"FormularyType":"OHP","DrugName":"CVS MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"59779037462"},{"Id":406648,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779037708"},{"Id":406649,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"59779041862"},{"Id":406650,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779042098"},{"Id":406651,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"59779042296"},{"Id":406652,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779042816"},{"Id":406653,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"59779043162"},{"Id":406654,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"59779043262"},{"Id":406655,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"59779043267"},{"Id":406656,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"59779043280"},{"Id":406657,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"59779044101"},{"Id":406658,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"59779044374"},{"Id":406659,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"59779044574"},{"Id":406660,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"59779044870"},{"Id":406661,"FormularyType":"OHP","DrugName":"CVS NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"59779044874"},{"Id":406662,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045839"},{"Id":406663,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045866"},{"Id":406664,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045870"},{"Id":406665,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045875"},{"Id":406666,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045876"},{"Id":406667,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045888"},{"Id":406668,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"59779045895"},{"Id":406669,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"59779046708"},{"Id":406670,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"59779046768"},{"Id":406671,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG CINN","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779048244"},{"Id":406672,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"59779048344"},{"Id":406673,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"59779050156"},{"Id":406674,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779050344"},{"Id":406675,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"59779050926"},{"Id":406676,"FormularyType":"OHP","DrugName":"CVS RINGWORM CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"59779051401"},{"Id":406677,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"59779051778"},{"Id":406678,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"59779052301"},{"Id":406679,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"59779053664"},{"Id":406680,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"59779054478"},{"Id":406681,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"59779054750"},{"Id":406682,"FormularyType":"OHP","DrugName":"FEVR REDUCNG SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"59779057953"},{"Id":406683,"FormularyType":"OHP","DrugName":"ALLERGY CHIL CHW 12.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100510","GenericName":"DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG","NDC":"59779058507"},{"Id":406684,"FormularyType":"OHP","DrugName":"CVS ALLERGY TAB CHLDRN","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"59779058544"},{"Id":406685,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"59779059016"},{"Id":406686,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779060006"},{"Id":406687,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779060014"},{"Id":406688,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779060016"},{"Id":406689,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779060017"},{"Id":406690,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779060027"},{"Id":406691,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"59779060462"},{"Id":406692,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"59779060490"},{"Id":406693,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779060815"},{"Id":406694,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779060850"},{"Id":406695,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"59779060898"},{"Id":406696,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"59779060915"},{"Id":406697,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"59779060950"},{"Id":406698,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"59779060998"},{"Id":406699,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59779061246"},{"Id":406700,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59779061270"},{"Id":406701,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59779061275"},{"Id":406702,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59779061288"},{"Id":406703,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"59779061295"},{"Id":406704,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"59779064771"},{"Id":406705,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"59779064778"},{"Id":406706,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779066026"},{"Id":406707,"FormularyType":"OHP","DrugName":"CVS IBUPROFE SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779066034"},{"Id":406708,"FormularyType":"OHP","DrugName":"CVS C-LAX TAB 5MG","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"59779067613"},{"Id":406709,"FormularyType":"OHP","DrugName":"CVS IBUPROFE SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779068526"},{"Id":406710,"FormularyType":"OHP","DrugName":"CVS IBUPROFE SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779068534"},{"Id":406711,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"59779070352"},{"Id":406712,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"59779070360"},{"Id":406713,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"59779070501"},{"Id":406714,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779072714"},{"Id":406715,"FormularyType":"OHP","DrugName":"CVS MICONAZO CRE 7","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"59779073041"},{"Id":406716,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779073401"},{"Id":406717,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779073402"},{"Id":406718,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779073404"},{"Id":406719,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"59779073460"},{"Id":406720,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"59779074601"},{"Id":406721,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"59779077287"},{"Id":406722,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"59779078508"},{"Id":406723,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"59779083726"},{"Id":406724,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"59779083734"},{"Id":406725,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"59779086322"},{"Id":406726,"FormularyType":"OHP","DrugName":"CVS ALLERGY CHW 12.5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030107210","GenericName":"DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG","NDC":"59779086944"},{"Id":406727,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"59779087304"},{"Id":406728,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"59779087308"},{"Id":406729,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"59779087311"},{"Id":406730,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"59779087426"},{"Id":406731,"FormularyType":"OHP","DrugName":"CORTISONE LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"59779087825"},{"Id":406732,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"59779088426"},{"Id":406733,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779089726"},{"Id":406734,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"59779089734"},{"Id":406735,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"59779092001"},{"Id":406736,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"59779092308"},{"Id":406737,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"59779092312"},{"Id":406738,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"59779092322"},{"Id":406739,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"59779092351"},{"Id":406740,"FormularyType":"OHP","DrugName":"CVS MENSTRUA TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"59779093008"},{"Id":406741,"FormularyType":"OHP","DrugName":"CVS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"59779094532"},{"Id":406742,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"59779094616"},{"Id":406743,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"59779095704"},{"Id":406744,"FormularyType":"OHP","DrugName":"CVS NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"59779095760"},{"Id":406745,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"59779095911"},{"Id":406746,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"59779095935"},{"Id":406747,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"59779097547"},{"Id":406748,"FormularyType":"OHP","DrugName":"JUVEN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"59781071164"},{"Id":406749,"FormularyType":"OHP","DrugName":"FLUORIDEX PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"59883001604"},{"Id":406750,"FormularyType":"OHP","DrugName":"FLUORIDEX PST 1.1%","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"59883002004"},{"Id":406751,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 8MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000205","GenericName":"POTASSIUM CHLORIDE CAP ER 8 MEQ","NDC":"59917010201"},{"Id":406752,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"59917010301"},{"Id":406753,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"59917010305"},{"Id":406754,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"59923070305"},{"Id":406755,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"59923070414"},{"Id":406756,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"59923070505"},{"Id":406757,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"59923070614"},{"Id":406758,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"59923070814"},{"Id":406759,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"59923071014"},{"Id":406760,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"59923072160"},{"Id":406761,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60000052651"},{"Id":406762,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"60000052652"},{"Id":406763,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"60000052653"},{"Id":406764,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"60000052654"},{"Id":406765,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"60000052655"},{"Id":406766,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"60000052656"},{"Id":406767,"FormularyType":"OHP","DrugName":"EASY COMFORT PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60000052657"},{"Id":406768,"FormularyType":"OHP","DrugName":"SAPS HEALTH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60000052658"},{"Id":406769,"FormularyType":"OHP","DrugName":"PEAK FLW MTR MIS ADULT","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"60000052659"},{"Id":406770,"FormularyType":"OHP","DrugName":"REASON LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60000091352"},{"Id":406771,"FormularyType":"OHP","DrugName":"REASON LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60000091353"},{"Id":406772,"FormularyType":"OHP","DrugName":"REASON LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60000091354"},{"Id":406773,"FormularyType":"OHP","DrugName":"REASON LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60000091355"},{"Id":406774,"FormularyType":"OHP","DrugName":"REASON LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60000091356"},{"Id":406775,"FormularyType":"OHP","DrugName":"REASON LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60000091357"},{"Id":406776,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"60002025931"},{"Id":406777,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"60002025932"},{"Id":406778,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"60002025933"},{"Id":406779,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"60002025934"},{"Id":406780,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"60002025935"},{"Id":406781,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"60002025936"},{"Id":406782,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"60002025937"},{"Id":406783,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"60002025938"},{"Id":406784,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"60002025939"},{"Id":406785,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"60002025940"},{"Id":406786,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"60002025941"},{"Id":406787,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"60002025942"},{"Id":406788,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"60002025943"},{"Id":406789,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"60002025944"},{"Id":406790,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"60002025945"},{"Id":406791,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"60002035771"},{"Id":406792,"FormularyType":"OHP","DrugName":"ULTRA FLO MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"60002035772"},{"Id":406793,"FormularyType":"OHP","DrugName":"ULTRA FLO MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"60002035773"},{"Id":406794,"FormularyType":"OHP","DrugName":"ULTRA FLO MIS PEN NEED","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"60002035774"},{"Id":406795,"FormularyType":"OHP","DrugName":"ULTRA FLO MIS PEN NEED","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"60002035776"},{"Id":406796,"FormularyType":"OHP","DrugName":"KALE/QUINOA POW BERRIES","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60002063350"},{"Id":406797,"FormularyType":"OHP","DrugName":"CHICKEN/PEAS POW CARROTS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60002063351"},{"Id":406798,"FormularyType":"OHP","DrugName":"RESTORE RENA POW SUPPORT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60002063352"},{"Id":406799,"FormularyType":"OHP","DrugName":"RESTORE FUS POW RENAL","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60002063353"},{"Id":406800,"FormularyType":"OHP","DrugName":"PURE COMFORT PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60003012550"},{"Id":406801,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"60003012551"},{"Id":406802,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"60003012552"},{"Id":406803,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"60003012553"},{"Id":406804,"FormularyType":"OHP","DrugName":"PURE COMFORT MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"60003012554"},{"Id":406805,"FormularyType":"OHP","DrugName":"PEAK FLW MTR MIS CHILD","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"60003012557"},{"Id":406806,"FormularyType":"OHP","DrugName":"ON/GO COVID KIT ANTIGEN","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60006019166"},{"Id":406807,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60006037780"},{"Id":406808,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"60006037786"},{"Id":406809,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"60006037787"},{"Id":406810,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"60006037788"},{"Id":406811,"FormularyType":"OHP","DrugName":"AFTERPILL TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"60007044930"},{"Id":406812,"FormularyType":"OHP","DrugName":"ON/GO ONE KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60007093040"},{"Id":406813,"FormularyType":"OHP","DrugName":"ENTERADE LIQ IBS-D","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60008032111"},{"Id":406814,"FormularyType":"OHP","DrugName":"ENTERADE LIQ WATERMEL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60008032112"},{"Id":406815,"FormularyType":"OHP","DrugName":"ENTERADE LIQ BERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60008032113"},{"Id":406816,"FormularyType":"OHP","DrugName":"ENTERADE LIQ IBS-D","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60008032119"},{"Id":406817,"FormularyType":"OHP","DrugName":"INDICAID KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60008040780"},{"Id":406818,"FormularyType":"OHP","DrugName":"INDICAID KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60008040781"},{"Id":406819,"FormularyType":"OHP","DrugName":"COVID-19 RAP KIT 1-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60008095486"},{"Id":406820,"FormularyType":"OHP","DrugName":"COVID-19 RAP KIT 2-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60008095487"},{"Id":406821,"FormularyType":"OHP","DrugName":"BIOLYTE SOL PUNCH","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"60009003160"},{"Id":406822,"FormularyType":"OHP","DrugName":"BIOLYTE SOL PUNCH","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"60009003161"},{"Id":406823,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60009074320"},{"Id":406824,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60009074321"},{"Id":406825,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60009074322"},{"Id":406826,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60009074323"},{"Id":406827,"FormularyType":"OHP","DrugName":"ADVIN 2-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60010003310"},{"Id":406828,"FormularyType":"OHP","DrugName":"ADVIN 1-PK KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"60010003312"},{"Id":406829,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"60011079030"},{"Id":406830,"FormularyType":"OHP","DrugName":"SERACAL POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60012067650"},{"Id":406831,"FormularyType":"OHP","DrugName":"PKU TRIO POW UNFLAVOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60014005180"},{"Id":406832,"FormularyType":"OHP","DrugName":"UCD TRIO POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60014005182"},{"Id":406833,"FormularyType":"OHP","DrugName":"SUPERIOR CAP OMEGA3","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"60168000213"},{"Id":406834,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"60219107601"},{"Id":406835,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"60219116507"},{"Id":406836,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"60219126401"},{"Id":406837,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"60219126501"},{"Id":406838,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"60219126601"},{"Id":406839,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100340","GenericName":"ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","NDC":"60219141403"},{"Id":406840,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100330","GenericName":"ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","NDC":"60219141503"},{"Id":406841,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100320","GenericName":"ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","NDC":"60219141603"},{"Id":406842,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100310","GenericName":"ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","NDC":"60219141703"},{"Id":406843,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"60219142501"},{"Id":406844,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"60219142505"},{"Id":406845,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"60219146701"},{"Id":406846,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"60219152201"},{"Id":406847,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"60219152301"},{"Id":406848,"FormularyType":"OHP","DrugName":"FLUOROMETHOL SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300020001810","GenericName":"FLUOROMETHOLONE OPHTH SUSP 0.1%","NDC":"60219158503"},{"Id":406849,"FormularyType":"OHP","DrugName":"FLUOROMETHOL SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300020001810","GenericName":"FLUOROMETHOLONE OPHTH SUSP 0.1%","NDC":"60219158606"},{"Id":406850,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"60219159502"},{"Id":406851,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"60219164008"},{"Id":406852,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"60219164009"},{"Id":406853,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"60219164109"},{"Id":406854,"FormularyType":"OHP","DrugName":"PIRFENIDONE CAP 267MG","DosageForm":"CAPS - Capsule","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000120","GenericName":"PIRFENIDONE CAP 267 MG","NDC":"60219164207"},{"Id":406855,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"60219165601"},{"Id":406856,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"60219170501"},{"Id":406857,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"60219170601"},{"Id":406858,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"60219170607"},{"Id":406859,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"60219170701"},{"Id":406860,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"60219170705"},{"Id":406861,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"60219170801"},{"Id":406862,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"60219170805"},{"Id":406863,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"60219171401"},{"Id":406864,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"60219171501"},{"Id":406865,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"60219171601"},{"Id":406866,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"60219171701"},{"Id":406867,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"60219171801"},{"Id":406868,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"60219171901"},{"Id":406869,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000320","GenericName":"ETRAVIRINE TAB 100 MG","NDC":"60219172107"},{"Id":406870,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000340","GenericName":"ETRAVIRINE TAB 200 MG","NDC":"60219172206"},{"Id":406871,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"60219174802"},{"Id":406872,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"60219174903"},{"Id":406873,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"60219175008"},{"Id":406874,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"60219175406"},{"Id":406875,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"60219203301"},{"Id":406876,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"60219203401"},{"Id":406877,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"60219203801"},{"Id":406878,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"60219203901"},{"Id":406879,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"60219204301"},{"Id":406880,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"60219204401"},{"Id":406881,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"60219204501"},{"Id":406882,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"60219204601"},{"Id":406883,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"60219205601"},{"Id":406884,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SOL 1% OTIC","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991003102010","GenericName":"NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%","NDC":"60219208301"},{"Id":406885,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"60219209004"},{"Id":406886,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"60219210407"},{"Id":406887,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007310","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 2 MG","NDC":"60219227901"},{"Id":406888,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007310","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 2 MG","NDC":"60219227902"},{"Id":406889,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 3MG","DosageForm":"TBSO - Tablet Soluble","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007320","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 3 MG","NDC":"60219228001"},{"Id":406890,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 3MG","DosageForm":"TBSO - Tablet Soluble","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007320","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 3 MG","NDC":"60219228002"},{"Id":406891,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007340","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 5 MG","NDC":"60219228101"},{"Id":406892,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007340","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 5 MG","NDC":"60219228102"},{"Id":406893,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"60219234801"},{"Id":406894,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"60219234805"},{"Id":406895,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"60219234807"},{"Id":406896,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"60219255001"},{"Id":406897,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"60219255101"},{"Id":406898,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"60219255201"},{"Id":406899,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"60219395501"},{"Id":406900,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"60219395503"},{"Id":406901,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"60219551109"},{"Id":406902,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"60219552205"},{"Id":406903,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"60219552209"},{"Id":406904,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"60219592201"},{"Id":406905,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"60236047373"},{"Id":406906,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"60236047374"},{"Id":406907,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"60236086175"},{"Id":406908,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG CHRY","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"60236086176"},{"Id":406909,"FormularyType":"OHP","DrugName":"CYTRA K GRA CRYSTALS","DosageForm":"PACK - Packet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202022003010","GenericName":"POTASSIUM CITRATE & CITRIC ACID POWDER PACK 3300-1002 MG","NDC":"60258000501"},{"Id":406910,"FormularyType":"OHP","DrugName":"SF 5000 PLUS CRE 1.1%","DosageForm":"CREA - Cream","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020003721","GenericName":"SODIUM FLUORIDE CREAM 1.1%","NDC":"60258015001"},{"Id":406911,"FormularyType":"OHP","DrugName":"SF GEL 1.1%","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"60258015101"},{"Id":406912,"FormularyType":"OHP","DrugName":"RENA-VITE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"60258016001"},{"Id":406913,"FormularyType":"OHP","DrugName":"RENA-VITE RX TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000330","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 1 MG***","NDC":"60258016101"},{"Id":406914,"FormularyType":"OHP","DrugName":"RENAL CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000130","GenericName":"*B-COMPLEX W/ C & FOLIC ACID CAP 1 MG***","NDC":"60258016201"},{"Id":406915,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"60258017101"},{"Id":406916,"FormularyType":"OHP","DrugName":"PRENATAL-U CAP 106.5-1","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512050000162","GenericName":"*PRENATAL W/O A VIT W/ FE FUMARATE-FA CAP 106.5-1 MG***","NDC":"60258017901"},{"Id":406917,"FormularyType":"OHP","DrugName":"POLY-IRON CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"60258018501"},{"Id":406918,"FormularyType":"OHP","DrugName":"PRENATABS FA TAB 29-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000332","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 29-1 MG***","NDC":"60258019001"},{"Id":406919,"FormularyType":"OHP","DrugName":"TRINATE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000329","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG***","NDC":"60258019201"},{"Id":406920,"FormularyType":"OHP","DrugName":"PRENATABS RX TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512010000330","GenericName":"*PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG***","NDC":"60258019309"},{"Id":406921,"FormularyType":"OHP","DrugName":"PRENATAL 19 CHW TAB","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000530","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***","NDC":"60258019701"},{"Id":406922,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"60322000010"},{"Id":406923,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"60322000011"},{"Id":406924,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"60322000012"},{"Id":406925,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"60322000013"},{"Id":406926,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"60322000014"},{"Id":406927,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"60322000015"},{"Id":406928,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"60322000016"},{"Id":406929,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"60322000017"},{"Id":406930,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"60322000018"},{"Id":406931,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"60322000019"},{"Id":406932,"FormularyType":"OHP","DrugName":"PKU START POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"60385094058"},{"Id":406933,"FormularyType":"OHP","DrugName":"DILT-XR CAP 120MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"60505001406"},{"Id":406934,"FormularyType":"OHP","DrugName":"DILT-XR CAP 120MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"60505001408"},{"Id":406935,"FormularyType":"OHP","DrugName":"DILT-XR CAP 180MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"60505001506"},{"Id":406936,"FormularyType":"OHP","DrugName":"DILT-XR CAP 180MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"60505001508"},{"Id":406937,"FormularyType":"OHP","DrugName":"DILT-XR CAP 240MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"60505001606"},{"Id":406938,"FormularyType":"OHP","DrugName":"DILT-XR CAP 240MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"60505001608"},{"Id":406939,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"60505003306"},{"Id":406940,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"60505003307"},{"Id":406941,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000120","GenericName":"ETODOLAC CAP 200 MG","NDC":"60505003901"},{"Id":406942,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000130","GenericName":"ETODOLAC CAP 300 MG","NDC":"60505004001"},{"Id":406943,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000310","GenericName":"ETODOLAC TAB 400 MG","NDC":"60505004101"},{"Id":406944,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"60505004206"},{"Id":406945,"FormularyType":"OHP","DrugName":"SELEGILINE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100120","GenericName":"SELEGILINE HCL CAP 5 MG","NDC":"60505005501"},{"Id":406946,"FormularyType":"OHP","DrugName":"SELEGILINE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100120","GenericName":"SELEGILINE HCL CAP 5 MG","NDC":"60505005502"},{"Id":406947,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"60505006500"},{"Id":406948,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"60505006501"},{"Id":406949,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"60505006502"},{"Id":406950,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"60505008000"},{"Id":406951,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100320","GenericName":"SOTALOL HCL TAB 160 MG","NDC":"60505008100"},{"Id":406952,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100330","GenericName":"SOTALOL HCL TAB 240 MG","NDC":"60505008200"},{"Id":406953,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"60505009300"},{"Id":406954,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"60505009301"},{"Id":406955,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"60505009400"},{"Id":406956,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"60505009401"},{"Id":406957,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"60505009500"},{"Id":406958,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"60505009501"},{"Id":406959,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"60505009600"},{"Id":406960,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"60505009601"},{"Id":406961,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000320","GenericName":"ETODOLAC TAB 500 MG","NDC":"60505010201"},{"Id":406962,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020000110","GenericName":"CYCLOSPORINE CAP 25 MG","NDC":"60505013300"},{"Id":406963,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020000140","GenericName":"CYCLOSPORINE CAP 100 MG","NDC":"60505013400"},{"Id":406964,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"60505014100"},{"Id":406965,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"60505014101"},{"Id":406966,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"60505014102"},{"Id":406967,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"60505014108"},{"Id":406968,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"60505014200"},{"Id":406969,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"60505014201"},{"Id":406970,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"60505014202"},{"Id":406971,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"60505014204"},{"Id":406972,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"60505014500"},{"Id":406973,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"60505014502"},{"Id":406974,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"60505014600"},{"Id":406975,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"60505014601"},{"Id":406976,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"60505014602"},{"Id":406977,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"60505014708"},{"Id":406978,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"60505015900"},{"Id":406979,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"60505016805"},{"Id":406980,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"60505016809"},{"Id":406981,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"60505016907"},{"Id":406982,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"60505016909"},{"Id":406983,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"60505017007"},{"Id":406984,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"60505017009"},{"Id":406985,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"60505018300"},{"Id":406986,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"60505018301"},{"Id":406987,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120310","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 80 MG","NDC":"60505022201"},{"Id":406988,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120315","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 120 MG","NDC":"60505022301"},{"Id":406989,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120320","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 160 MG","NDC":"60505022401"},{"Id":406990,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"60505025102"},{"Id":406991,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"60505025103"},{"Id":406992,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"60505025202"},{"Id":406993,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"60505025203"},{"Id":406994,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"60505025302"},{"Id":406995,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"60505025303"},{"Id":406996,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100310","GenericName":"DESMOPRESSIN ACETATE TAB 0.1 MG","NDC":"60505025701"},{"Id":406997,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100320","GenericName":"DESMOPRESSIN ACETATE TAB 0.2 MG","NDC":"60505025801"},{"Id":406998,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"60505036301"},{"Id":406999,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"60505036302"},{"Id":407000,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"60505056000"},{"Id":407001,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"60505056001"},{"Id":407002,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"60505057701"},{"Id":407003,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"60505057702"},{"Id":407004,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"60505057703"},{"Id":407005,"FormularyType":"OHP","DrugName":"AZELASTINE DRO 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802006102020","GenericName":"AZELASTINE HCL OPHTH SOLN 0.05%","NDC":"60505057804"},{"Id":407006,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"60505058204"},{"Id":407007,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"60505058301"},{"Id":407008,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"60505058304"},{"Id":407009,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"60505059301"},{"Id":407010,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"60505059304"},{"Id":407011,"FormularyType":"OHP","DrugName":"DESMOPRESSIN SPR 0.01%","DosageForm":"SOLN - Solution","Strength":"0.01","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010132010","GenericName":"DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01%","NDC":"60505081500"},{"Id":407012,"FormularyType":"OHP","DrugName":"CALCITONIN SPR 200/ACT","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30043020002080","GenericName":"CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT","NDC":"60505082306"},{"Id":407013,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"60505082601"},{"Id":407014,"FormularyType":"OHP","DrugName":"FLUTICASONE SPR 50MCG","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200032301810","GenericName":"FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT","NDC":"60505082901"},{"Id":407015,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"60505083305"},{"Id":407016,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"60505100301"},{"Id":407017,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"60505100302"},{"Id":407018,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"60505132001"},{"Id":407019,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"60505132101"},{"Id":407020,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"60505132305"},{"Id":407021,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"60505132309"},{"Id":407022,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"60505132501"},{"Id":407023,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"60505250201"},{"Id":407024,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"60505250203"},{"Id":407025,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"60505250301"},{"Id":407026,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"60505250303"},{"Id":407027,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000320","GenericName":"CILOSTAZOL TAB 50 MG","NDC":"60505252101"},{"Id":407028,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000330","GenericName":"CILOSTAZOL TAB 100 MG","NDC":"60505252201"},{"Id":407029,"FormularyType":"OHP","DrugName":"BALSALAZIDE CAP 750MG","DosageForm":"CAPS - Capsule","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500020100120","GenericName":"BALSALAZIDE DISODIUM CAP 750 MG","NDC":"60505257507"},{"Id":407030,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"60505257808"},{"Id":407031,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"60505257809"},{"Id":407032,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"60505257908"},{"Id":407033,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"60505257909"},{"Id":407034,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"60505258008"},{"Id":407035,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"60505258009"},{"Id":407036,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"60505264201"},{"Id":407037,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"60505264203"},{"Id":407038,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"60505265601"},{"Id":407039,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"60505265605"},{"Id":407040,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"60505265701"},{"Id":407041,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"60505265705"},{"Id":407042,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"60505267108"},{"Id":407043,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"60505267109"},{"Id":407044,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"60505279500"},{"Id":407045,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 100MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006910","GenericName":"CARBAMAZEPINE CAP ER 12HR 100 MG","NDC":"60505280507"},{"Id":407046,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 200MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006920","GenericName":"CARBAMAZEPINE CAP ER 12HR 200 MG","NDC":"60505280607"},{"Id":407047,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN CAP 300MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020006930","GenericName":"CARBAMAZEPINE CAP ER 12HR 300 MG","NDC":"60505280707"},{"Id":407048,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"60505285009"},{"Id":407049,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"60505290009"},{"Id":407050,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"60505290103"},{"Id":407051,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"60505296507"},{"Id":407052,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"60505296607"},{"Id":407053,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"60505309702"},{"Id":407054,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"60505309704"},{"Id":407055,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 43MG","DosageForm":"CAPS - Capsule","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100104","GenericName":"FENOFIBRATE MICRONIZED CAP 43 MG","NDC":"60505312003"},{"Id":407056,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"60505316500"},{"Id":407057,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000310","GenericName":"FAMCICLOVIR TAB 250 MG","NDC":"60505324603"},{"Id":407058,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000320","GenericName":"FAMCICLOVIR TAB 500 MG","NDC":"60505324703"},{"Id":407059,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352050000315","GenericName":"LAMIVUDINE TAB 100 MG (HBV)","NDC":"60505325006"},{"Id":407060,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"60505325106"},{"Id":407061,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000330","GenericName":"LAMIVUDINE TAB 300 MG","NDC":"60505325203"},{"Id":407062,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007520","GenericName":"LEVETIRACETAM TAB ER 24HR 500 MG","NDC":"60505328006"},{"Id":407063,"FormularyType":"OHP","DrugName":"SELEGILINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100320","GenericName":"SELEGILINE HCL TAB 5 MG","NDC":"60505343803"},{"Id":407064,"FormularyType":"OHP","DrugName":"SELEGILINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100320","GenericName":"SELEGILINE HCL TAB 5 MG","NDC":"60505343808"},{"Id":407065,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"60505351706"},{"Id":407066,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"60505361305"},{"Id":407067,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"60505361405"},{"Id":407068,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"60505361504"},{"Id":407069,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"60505362806"},{"Id":407070,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"60505362906"},{"Id":407071,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"60505363006"},{"Id":407072,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"60505363103"},{"Id":407073,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"60505380202"},{"Id":407074,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"60505380203"},{"Id":407075,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"60505381603"},{"Id":407076,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"60505381703"},{"Id":407077,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"60505384801"},{"Id":407078,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"60505384901"},{"Id":407079,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"60505384905"},{"Id":407080,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"60505388207"},{"Id":407081,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"60505388307"},{"Id":407082,"FormularyType":"OHP","DrugName":"ADEFOV DIPIV TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352015100320","GenericName":"ADEFOVIR DIPIVOXIL TAB 10 MG","NDC":"60505394703"},{"Id":407083,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"60505403301"},{"Id":407084,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"60505418301"},{"Id":407085,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"60505431700"},{"Id":407086,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"60505431800"},{"Id":407087,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"60505432701"},{"Id":407088,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"60505433203"},{"Id":407089,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"60505434706"},{"Id":407090,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"60505434806"},{"Id":407091,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"60505434906"},{"Id":407092,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000110","GenericName":"POMALIDOMIDE CAP 1 MG","NDC":"60505449702"},{"Id":407093,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000115","GenericName":"POMALIDOMIDE CAP 2 MG","NDC":"60505449802"},{"Id":407094,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000120","GenericName":"POMALIDOMIDE CAP 3 MG","NDC":"60505449902"},{"Id":407095,"FormularyType":"OHP","DrugName":"POMALIDOMIDE CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21450080000125","GenericName":"POMALIDOMIDE CAP 4 MG","NDC":"60505450002"},{"Id":407096,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"60505453202"},{"Id":407097,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"60505453302"},{"Id":407098,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"60505453402"},{"Id":407099,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"60505453502"},{"Id":407100,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"60505453602"},{"Id":407101,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"60505453702"},{"Id":407102,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"60505455203"},{"Id":407103,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"60505455303"},{"Id":407104,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"60505463003"},{"Id":407105,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 50MG MOD","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300130","GenericName":"CYCLOSPORINE MODIFIED CAP 50 MG","NDC":"60505463103"},{"Id":407106,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"60505463203"},{"Id":407107,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100320","GenericName":"PRASUGREL HCL TAB 5 MG (BASE EQUIV)","NDC":"60505464203"},{"Id":407108,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"60505468107"},{"Id":407109,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"60505468209"},{"Id":407110,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"60505470203"},{"Id":407111,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"60505470303"},{"Id":407112,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"60505473901"},{"Id":407113,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"60505474001"},{"Id":407114,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"60505474101"},{"Id":407115,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"60505474201"},{"Id":407116,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"60505474301"},{"Id":407117,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"60505474401"},{"Id":407118,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"60505474501"},{"Id":407119,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"60505476406"},{"Id":407120,"FormularyType":"OHP","DrugName":"PAZOPANIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533042100320","GenericName":"PAZOPANIB HCL TAB 200 MG (BASE EQUIV)","NDC":"60505477907"},{"Id":407121,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100330","GenericName":"PRASUGREL HCL TAB 10 MG (BASE EQUIV)","NDC":"60505485603"},{"Id":407122,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"60505530601"},{"Id":407123,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"60505530701"},{"Id":407124,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"60505612902"},{"Id":407125,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"60505614200"},{"Id":407126,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"60505614205"},{"Id":407127,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"60505614300"},{"Id":407128,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"60505614304"},{"Id":407129,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"60505614400"},{"Id":407130,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"60505614404"},{"Id":407131,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"60505614500"},{"Id":407132,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"60505614504"},{"Id":407133,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"60505614600"},{"Id":407134,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"60505614604"},{"Id":407135,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"60505614700"},{"Id":407136,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"60505614704"},{"Id":407137,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"60505614800"},{"Id":407138,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"60505614804"},{"Id":407139,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"60505614900"},{"Id":407140,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"60505614904"},{"Id":407141,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102125","GenericName":"CEFTRIAXONE SODIUM FOR INJ 10 GM","NDC":"60505615005"},{"Id":407142,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"60505615101"},{"Id":407143,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102105","GenericName":"CEFTRIAXONE SODIUM FOR INJ 250 MG","NDC":"60505615104"},{"Id":407144,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"60505615201"},{"Id":407145,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102110","GenericName":"CEFTRIAXONE SODIUM FOR INJ 500 MG","NDC":"60505615204"},{"Id":407146,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"60505615600"},{"Id":407147,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"60505615604"},{"Id":407148,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"60505615700"},{"Id":407149,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"60505615704"},{"Id":407150,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"60505615900"},{"Id":407151,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"60505615904"},{"Id":407152,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"60505618406"},{"Id":407153,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"60505619600"},{"Id":407154,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"60505619604"},{"Id":407155,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"60505619702"},{"Id":407156,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"60505622600"},{"Id":407157,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"60505622601"},{"Id":407158,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"60505622602"},{"Id":407159,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102118","GenericName":"CEFAZOLIN SODIUM FOR INJ 2 GM","NDC":"60505623100"},{"Id":407160,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102118","GenericName":"CEFAZOLIN SODIUM FOR INJ 2 GM","NDC":"60505623105"},{"Id":407161,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"60505623500"},{"Id":407162,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"60505623504"},{"Id":407163,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"60505624300"},{"Id":407164,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"60505624304"},{"Id":407165,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"60505624400"},{"Id":407166,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"60505624404"},{"Id":407167,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"60505624500"},{"Id":407168,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"60505624504"},{"Id":407169,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"60505624600"},{"Id":407170,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"60505624604"},{"Id":407171,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"60505624901"},{"Id":407172,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"60505625001"},{"Id":407173,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000325","GenericName":"DEXAMETHASONE TAB 1 MG","NDC":"60505625101"},{"Id":407174,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"60505625201"},{"Id":407175,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"60505625301"},{"Id":407176,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"60505625401"},{"Id":407177,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"60505625501"},{"Id":407178,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 40.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"60505626200"},{"Id":407179,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"3","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102122","GenericName":"CEFAZOLIN SODIUM FOR INJ 3 GM","NDC":"60505626600"},{"Id":407180,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"3","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102122","GenericName":"CEFAZOLIN SODIUM FOR INJ 3 GM","NDC":"60505626605"},{"Id":407181,"FormularyType":"OHP","DrugName":"TRIAMCINOLON SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"60505627507"},{"Id":407182,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"60505706400"},{"Id":407183,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"60505706500"},{"Id":407184,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"60505706600"},{"Id":407185,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000000"},{"Id":407186,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000001"},{"Id":407187,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000002"},{"Id":407188,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000003"},{"Id":407189,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000004"},{"Id":407190,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000005"},{"Id":407191,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000006"},{"Id":407192,"FormularyType":"OHP","DrugName":"ORGANIC NUTR LIQ SHAKE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"60547000007"},{"Id":407193,"FormularyType":"OHP","DrugName":"ZOSTRIX NAT CRE 0.033%","DosageForm":"CREA - Cream","Strength":"0.033","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003714","GenericName":"CAPSAICIN CREAM 0.033%","NDC":"60569044202"},{"Id":407194,"FormularyType":"OHP","DrugName":"MAGOX 400 TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"60569049412"},{"Id":407195,"FormularyType":"OHP","DrugName":"MAGOX 400 TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"60569049460"},{"Id":407196,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"60687028311"},{"Id":407197,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"60687028394"},{"Id":407198,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"60687039579"},{"Id":407199,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"60687039583"},{"Id":407200,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"60687040579"},{"Id":407201,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"60687040583"},{"Id":407202,"FormularyType":"OHP","DrugName":"HEALTHYLAX POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"60687043127"},{"Id":407203,"FormularyType":"OHP","DrugName":"HEALTHYLAX POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"60687043192"},{"Id":407204,"FormularyType":"OHP","DrugName":"HEALTHYLAX POW","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"60687043198"},{"Id":407205,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"60687069911"},{"Id":407206,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"60687069921"},{"Id":407207,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"60687073808"},{"Id":407208,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"60687073823"},{"Id":407209,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"60687073856"},{"Id":407210,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650MG","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"60687074024"},{"Id":407211,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 650MG","DosageForm":"SOLN - Solution","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"60687074037"},{"Id":407212,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"60687075142"},{"Id":407213,"FormularyType":"OHP","DrugName":"ACETAMIN SOL 325MG","DosageForm":"SOLN - Solution","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"60687075156"},{"Id":407214,"FormularyType":"OHP","DrugName":"LINEZOLID SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040001920","GenericName":"LINEZOLID FOR SUSP 100 MG/5ML","NDC":"60687075405"},{"Id":407215,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"60687076217"},{"Id":407216,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"60687076240"},{"Id":407217,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"60687076513"},{"Id":407218,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"60687077601"},{"Id":407219,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"60687077611"},{"Id":407220,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"60687078701"},{"Id":407221,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"60687078711"},{"Id":407222,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"60687079201"},{"Id":407223,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"60687079211"},{"Id":407224,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100303","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 500 MG","NDC":"60687079825"},{"Id":407225,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100303","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 500 MG","NDC":"60687079895"},{"Id":407226,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"60687080301"},{"Id":407227,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"60687080311"},{"Id":407228,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"60687080918"},{"Id":407229,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"60687080928"},{"Id":407230,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400/10ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"60687091608"},{"Id":407231,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400/10ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"60687091656"},{"Id":407232,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 300/6ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"60687091941"},{"Id":407233,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 300/6ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"60687091987"},{"Id":407234,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"60687092740"},{"Id":407235,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"60687092786"},{"Id":407236,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"60758011905"},{"Id":407237,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"60758011910"},{"Id":407238,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"60758011915"},{"Id":407239,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"60758080105"},{"Id":407240,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"60758080110"},{"Id":407241,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"60758080205"},{"Id":407242,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"60758080210"},{"Id":407243,"FormularyType":"OHP","DrugName":"FLUOROMETHOL SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300020001810","GenericName":"FLUOROMETHOLONE OPHTH SUSP 0.1%","NDC":"60758088005"},{"Id":407244,"FormularyType":"OHP","DrugName":"FLUOROMETHOL SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300020001810","GenericName":"FLUOROMETHOLONE OPHTH SUSP 0.1%","NDC":"60758088010"},{"Id":407245,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"60793085001"},{"Id":407246,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"60793085010"},{"Id":407247,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"60793085101"},{"Id":407248,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"60793085110"},{"Id":407249,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"60793085201"},{"Id":407250,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"60793085210"},{"Id":407251,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"60793085301"},{"Id":407252,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"60793085310"},{"Id":407253,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"60793085401"},{"Id":407254,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"60793085410"},{"Id":407255,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"60793085501"},{"Id":407256,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"60793085510"},{"Id":407257,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"60793085601"},{"Id":407258,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"60793085610"},{"Id":407259,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"60793085701"},{"Id":407260,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"60793085710"},{"Id":407261,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"60793085801"},{"Id":407262,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"60793085810"},{"Id":407263,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"60793085901"},{"Id":407264,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"60793085910"},{"Id":407265,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"60793086001"},{"Id":407266,"FormularyType":"OHP","DrugName":"LEVOXYL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"60793086010"},{"Id":407267,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI TAB ER 105MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"105","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"CHOLINESTERASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93250060207520","GenericName":"PYRIDOSTIGMINE BROMIDE TAB ER 24HR 105 MG (PROTECTIVE)","NDC":"60846055910"},{"Id":407268,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI TAB ER 105MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"105","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"CHOLINESTERASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93250060207520","GenericName":"PYRIDOSTIGMINE BROMIDE TAB ER 24HR 105 MG (PROTECTIVE)","NDC":"60846055927"},{"Id":407269,"FormularyType":"OHP","DrugName":"UNITHROID TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"60846080101"},{"Id":407270,"FormularyType":"OHP","DrugName":"UNITHROID TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"60846080201"},{"Id":407271,"FormularyType":"OHP","DrugName":"UNITHROID TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"60846080301"},{"Id":407272,"FormularyType":"OHP","DrugName":"UNITHROID TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"60846080401"},{"Id":407273,"FormularyType":"OHP","DrugName":"UNITHROID TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"60846080501"},{"Id":407274,"FormularyType":"OHP","DrugName":"UNITHROID TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"60846080601"},{"Id":407275,"FormularyType":"OHP","DrugName":"UNITHROID TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"60846080701"},{"Id":407276,"FormularyType":"OHP","DrugName":"UNITHROID TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"60846080801"},{"Id":407277,"FormularyType":"OHP","DrugName":"UNITHROID TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"60846080901"},{"Id":407278,"FormularyType":"OHP","DrugName":"UNITHROID TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"60846081001"},{"Id":407279,"FormularyType":"OHP","DrugName":"UNITHROID TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"60846081101"},{"Id":407280,"FormularyType":"OHP","DrugName":"UNITHROID TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"60846081201"},{"Id":407281,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60913000601"},{"Id":407282,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60913002501"},{"Id":407283,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60913002502"},{"Id":407284,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60913002503"},{"Id":407285,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"60913002504"},{"Id":407286,"FormularyType":"OHP","DrugName":"ENDOCET TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"60951060270"},{"Id":407287,"FormularyType":"OHP","DrugName":"ENDOCET TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"60951060285"},{"Id":407288,"FormularyType":"OHP","DrugName":"ENDOCET TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"60951070070"},{"Id":407289,"FormularyType":"OHP","DrugName":"ENDOCET TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"60951071270"},{"Id":407290,"FormularyType":"OHP","DrugName":"PENTIPS MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"61059042987"},{"Id":407291,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"61059043087"},{"Id":407292,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059044087"},{"Id":407293,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"61059045087"},{"Id":407294,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"61059049087"},{"Id":407295,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"61059052988"},{"Id":407296,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"61059053085"},{"Id":407297,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"61059053087"},{"Id":407298,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"61059053088"},{"Id":407299,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059054085"},{"Id":407300,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059054087"},{"Id":407301,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059054088"},{"Id":407302,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"61059055085"},{"Id":407303,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"61059055087"},{"Id":407304,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"61059055088"},{"Id":407305,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059056036"},{"Id":407306,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"61059059085"},{"Id":407307,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"61059059536"},{"Id":407308,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"61059059587"},{"Id":407309,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"61059059588"},{"Id":407310,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059064000"},{"Id":407311,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059064100"},{"Id":407312,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"61059065000"},{"Id":407313,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"61059065100"},{"Id":407314,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"61059086036"},{"Id":407315,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61145010106"},{"Id":407316,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61145010109"},{"Id":407317,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61145010118"},{"Id":407318,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61145010206"},{"Id":407319,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61145010212"},{"Id":407320,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61145010218"},{"Id":407321,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1% VAG","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003705","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 1%","NDC":"61269022041"},{"Id":407322,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1% VAG","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003705","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 1%","NDC":"61269022063"},{"Id":407323,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"61269073041"},{"Id":407324,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"61269073063"},{"Id":407325,"FormularyType":"OHP","DrugName":"HAELAN HTPI LIQ FERMENTE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"61287000020"},{"Id":407326,"FormularyType":"OHP","DrugName":"HAELAN 951 LIQ FERMENTE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"61287000021"},{"Id":407327,"FormularyType":"OHP","DrugName":"DICLOFENAC SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805010102010","GenericName":"DICLOFENAC SODIUM OPHTH SOLN 0.1%","NDC":"61314001405"},{"Id":407328,"FormularyType":"OHP","DrugName":"DICLOFENAC SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805010102010","GenericName":"DICLOFENAC SODIUM OPHTH SOLN 0.1%","NDC":"61314001425"},{"Id":407329,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"61314001910"},{"Id":407330,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"61314003002"},{"Id":407331,"FormularyType":"OHP","DrugName":"TRIFLURIDINE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86103020002005","GenericName":"TRIFLURIDINE OPHTH SOLN 1%","NDC":"61314004475"},{"Id":407332,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"61314012605"},{"Id":407333,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"61314012610"},{"Id":407334,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"61314014305"},{"Id":407335,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"61314014310"},{"Id":407336,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"61314014315"},{"Id":407337,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102015","GenericName":"PILOCARPINE HCL OPHTH SOLN 1%","NDC":"61314020315"},{"Id":407338,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102020","GenericName":"PILOCARPINE HCL OPHTH SOLN 2%","NDC":"61314020415"},{"Id":407339,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 4% OP","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102030","GenericName":"PILOCARPINE HCL OPHTH SOLN 4%","NDC":"61314020615"},{"Id":407340,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"61314022405"},{"Id":407341,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"61314022605"},{"Id":407342,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"61314022610"},{"Id":407343,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"61314022615"},{"Id":407344,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"61314022705"},{"Id":407345,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"61314022710"},{"Id":407346,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"61314022715"},{"Id":407347,"FormularyType":"OHP","DrugName":"BETAXOLOL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250010102005","GenericName":"BETAXOLOL HCL OPHTH SOLN 0.5%","NDC":"61314024501"},{"Id":407348,"FormularyType":"OHP","DrugName":"BETAXOLOL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250010102005","GenericName":"BETAXOLOL HCL OPHTH SOLN 0.5%","NDC":"61314024502"},{"Id":407349,"FormularyType":"OHP","DrugName":"BETAXOLOL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250010102005","GenericName":"BETAXOLOL HCL OPHTH SOLN 0.5%","NDC":"61314024503"},{"Id":407350,"FormularyType":"OHP","DrugName":"AZELASTINE DRO 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802006102020","GenericName":"AZELASTINE HCL OPHTH SOLN 0.05%","NDC":"61314030802"},{"Id":407351,"FormularyType":"OHP","DrugName":"TROPICAMIDE SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350050002005","GenericName":"TROPICAMIDE OPHTH SOLN 0.5%","NDC":"61314035401"},{"Id":407352,"FormularyType":"OHP","DrugName":"TROPICAMIDE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350050002010","GenericName":"TROPICAMIDE OPHTH SOLN 1%","NDC":"61314035501"},{"Id":407353,"FormularyType":"OHP","DrugName":"TROPICAMIDE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350050002010","GenericName":"TROPICAMIDE OPHTH SOLN 1%","NDC":"61314035502"},{"Id":407354,"FormularyType":"OHP","DrugName":"CYCLOPENTOL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350020102010","GenericName":"CYCLOPENTOLATE HCL OPHTH SOLN 1%","NDC":"61314039601"},{"Id":407355,"FormularyType":"OHP","DrugName":"CYCLOPENTOL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350020102010","GenericName":"CYCLOPENTOLATE HCL OPHTH SOLN 1%","NDC":"61314039603"},{"Id":407356,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"61314054701"},{"Id":407357,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"61314054703"},{"Id":407358,"FormularyType":"OHP","DrugName":"POLYMYXIN B/ SOL TRIMETHP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86109902602020","GenericName":"POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1%","NDC":"61314062810"},{"Id":407359,"FormularyType":"OHP","DrugName":"NEO/POLY/DEX SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309903321810","GenericName":"NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%","NDC":"61314063006"},{"Id":407360,"FormularyType":"OHP","DrugName":"NEO/POLY/DEX OIN 0.1% OP","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309903324210","GenericName":"NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%","NDC":"61314063136"},{"Id":407361,"FormularyType":"OHP","DrugName":"GENTAMICIN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101030002005","GenericName":"GENTAMICIN SULFATE OPHTH SOLN 0.3%","NDC":"61314063305"},{"Id":407362,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"61314063705"},{"Id":407363,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"61314063710"},{"Id":407364,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"61314063715"},{"Id":407365,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SUS OP","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309903341810","GenericName":"NEOMYCIN-POLYMYXIN-HC OPHTH SUSP","NDC":"61314064175"},{"Id":407366,"FormularyType":"OHP","DrugName":"TOBRAMYCIN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101070002005","GenericName":"TOBRAMYCIN OPHTH SOLN 0.3%","NDC":"61314064305"},{"Id":407367,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SUS 1% OTIC","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991003101807","GenericName":"NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%","NDC":"61314064511"},{"Id":407368,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SOL 1% OTIC","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991003102010","GenericName":"NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%","NDC":"61314064610"},{"Id":407369,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"61314064705"},{"Id":407370,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"61314064710"},{"Id":407371,"FormularyType":"OHP","DrugName":"TOBRA/DEXAME SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309902801820","GenericName":"TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","NDC":"61314064725"},{"Id":407372,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"61314065605"},{"Id":407373,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"61314065610"},{"Id":407374,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"61314065625"},{"Id":407375,"FormularyType":"OHP","DrugName":"APRACLONIDIN SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602010102010","GenericName":"APRACLONIDINE HCL OPHTH SOLN 0.5% (BASE EQUIVALENT)","NDC":"61314066505"},{"Id":407376,"FormularyType":"OHP","DrugName":"APRACLONIDIN SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602010102010","GenericName":"APRACLONIDINE HCL OPHTH SOLN 0.5% (BASE EQUIVALENT)","NDC":"61314066510"},{"Id":407377,"FormularyType":"OHP","DrugName":"GATIFLOXACIN SOL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101029002030","GenericName":"GATIFLOXACIN OPHTH SOLN 0.5%","NDC":"61314067225"},{"Id":407378,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 25MG DR","DosageForm":"TBEC - Tablet DR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200610","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG","NDC":"61442010101"},{"Id":407379,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61442010201"},{"Id":407380,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61442010210"},{"Id":407381,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61442010260"},{"Id":407382,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442010301"},{"Id":407383,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442010305"},{"Id":407384,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442010310"},{"Id":407385,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442010360"},{"Id":407386,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"61442011201"},{"Id":407387,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"61442011205"},{"Id":407388,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"61442011301"},{"Id":407389,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"61442011305"},{"Id":407390,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"61442011401"},{"Id":407391,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"61442011405"},{"Id":407392,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"61442011501"},{"Id":407393,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"61442011505"},{"Id":407394,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"61442011601"},{"Id":407395,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"61442011605"},{"Id":407396,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"61442011701"},{"Id":407397,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"61442011705"},{"Id":407398,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"61442012101"},{"Id":407399,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"61442012110"},{"Id":407400,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"61442012201"},{"Id":407401,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"61442012210"},{"Id":407402,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"61442012610"},{"Id":407403,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"61442012710"},{"Id":407404,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"61442014101"},{"Id":407405,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"61442014110"},{"Id":407406,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"61442014201"},{"Id":407407,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"61442014210"},{"Id":407408,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"61442014301"},{"Id":407409,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"61442014310"},{"Id":407410,"FormularyType":"OHP","DrugName":"CEFACLOR CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200040000105","GenericName":"CEFACLOR CAP 250 MG","NDC":"61442017130"},{"Id":407411,"FormularyType":"OHP","DrugName":"CEFACLOR CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200040000110","GenericName":"CEFACLOR CAP 500 MG","NDC":"61442017230"},{"Id":407412,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"61442019205"},{"Id":407413,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"61442019305"},{"Id":407414,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"61442022201"},{"Id":407415,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"61442022301"},{"Id":407416,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"61442022305"},{"Id":407417,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"61442022450"},{"Id":407418,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61442022601"},{"Id":407419,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61442022610"},{"Id":407420,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"61442022660"},{"Id":407421,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442022701"},{"Id":407422,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442022705"},{"Id":407423,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442022710"},{"Id":407424,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"61442022760"},{"Id":407425,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"61442031130"},{"Id":407426,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"61442043105"},{"Id":407427,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"61442043205"},{"Id":407428,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"61442043305"},{"Id":407429,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"61554023400"},{"Id":407430,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM/40ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"O","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102075","GenericName":"METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML)","NDC":"61703012440"},{"Id":407431,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 50MG/2ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102062","GenericName":"METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","NDC":"61703016102"},{"Id":407432,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 50MG/2ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102062","GenericName":"METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","NDC":"61703016105"},{"Id":407433,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102062","GenericName":"METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","NDC":"61703035009"},{"Id":407434,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102062","GenericName":"METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","NDC":"61703035010"},{"Id":407435,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102062","GenericName":"METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","NDC":"61703035037"},{"Id":407436,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102062","GenericName":"METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","NDC":"61703035038"},{"Id":407437,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"O","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102075","GenericName":"METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML)","NDC":"61703040825"},{"Id":407438,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM/40ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"O","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102075","GenericName":"METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML)","NDC":"61703040841"},{"Id":407439,"FormularyType":"OHP","DrugName":"PRALUENT INJ 75MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935001000D520","GenericName":"ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/ML","NDC":"61755002001"},{"Id":407440,"FormularyType":"OHP","DrugName":"PRALUENT INJ 75MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935001000D520","GenericName":"ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/ML","NDC":"61755002002"},{"Id":407441,"FormularyType":"OHP","DrugName":"PRALUENT INJ 150MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935001000D530","GenericName":"ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML","NDC":"61755002101"},{"Id":407442,"FormularyType":"OHP","DrugName":"PRALUENT INJ 150MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935001000D530","GenericName":"ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML","NDC":"61755002102"},{"Id":407443,"FormularyType":"OHP","DrugName":"FC2 FEMALE MIS CONDOM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401510000000","GenericName":"*CONDOMS - FEMALE***","NDC":"61783000012"},{"Id":407444,"FormularyType":"OHP","DrugName":"ZOSTRIX NAT CRE 0.033%","DosageForm":"CREA - Cream","Strength":"0.033","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003714","GenericName":"CAPSAICIN CREAM 0.033%","NDC":"61787044202"},{"Id":407445,"FormularyType":"OHP","DrugName":"VIREAD POW 40MG/GM","DosageForm":"POWD - Powder","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570102920","GenericName":"TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER 40 MG/GM","NDC":"61958040301"},{"Id":407446,"FormularyType":"OHP","DrugName":"VIREAD TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100305","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 150 MG","NDC":"61958040401"},{"Id":407447,"FormularyType":"OHP","DrugName":"VIREAD TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100310","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 200 MG","NDC":"61958040501"},{"Id":407448,"FormularyType":"OHP","DrugName":"VIREAD TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100315","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 250 MG","NDC":"61958040601"},{"Id":407449,"FormularyType":"OHP","DrugName":"EMTRIVA SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106030002010","GenericName":"EMTRICITABINE SOLN 10 MG/ML","NDC":"61958060201"},{"Id":407450,"FormularyType":"OHP","DrugName":"CAYSTON INH 75MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010402120","GenericName":"AZTREONAM LYSINE FOR INHAL SOLN 75 MG (BASE EQUIVALENT)","NDC":"61958090101"},{"Id":407451,"FormularyType":"OHP","DrugName":"STRIBILD TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109904300320","GenericName":"ELVITEGRAV-COBIC-EMTRICITAB-TENOFOVDF TAB 150-150-200-300 MG","NDC":"61958120101"},{"Id":407452,"FormularyType":"OHP","DrugName":"ZYDELIG TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21538040000320","GenericName":"IDELALISIB TAB 100 MG","NDC":"61958170101"},{"Id":407453,"FormularyType":"OHP","DrugName":"ZYDELIG TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21538040000330","GenericName":"IDELALISIB TAB 150 MG","NDC":"61958170201"},{"Id":407454,"FormularyType":"OHP","DrugName":"GENVOYA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109904290315","GenericName":"ELVITEGRAV-COBIC-EMTRICITAB-TENOFOV AF TAB 150-150-200-10 MG","NDC":"61958190101"},{"Id":407455,"FormularyType":"OHP","DrugName":"DESCOVY TAB 200/25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902290320","GenericName":"EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TAB 200-25 MG","NDC":"61958200201"},{"Id":407456,"FormularyType":"OHP","DrugName":"DESCOVY TAB 120-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902290310","GenericName":"EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TAB 120-15 MG","NDC":"61958200501"},{"Id":407457,"FormularyType":"OHP","DrugName":"ODEFSEY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903390320","GenericName":"EMTRICITABINE-RILPIVIRINE-TENOFOVIR AF TAB 200-25-25 MG","NDC":"61958210101"},{"Id":407458,"FormularyType":"OHP","DrugName":"VOSEVI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12359903800330","GenericName":"SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR TAB 400-100-100 MG","NDC":"61958240101"},{"Id":407459,"FormularyType":"OHP","DrugName":"BIKTARVY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903240330","GenericName":"BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 50-200-25 MG","NDC":"61958250101"},{"Id":407460,"FormularyType":"OHP","DrugName":"BIKTARVY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903240330","GenericName":"BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 50-200-25 MG","NDC":"61958250103"},{"Id":407461,"FormularyType":"OHP","DrugName":"BIKTARVY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903240320","GenericName":"BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 30-120-15 MG","NDC":"61958250501"},{"Id":407462,"FormularyType":"OHP","DrugName":"BIKTARVY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903240320","GenericName":"BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 30-120-15 MG","NDC":"61958250601"},{"Id":407463,"FormularyType":"OHP","DrugName":"LIVDELZI CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR(PPAR) AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52780070500120","GenericName":"SELADELPAR LYSINE CAP 10 MG","NDC":"61958330102"},{"Id":407464,"FormularyType":"OHP","DrugName":"HM ENEMA ENE R-T-U","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"62011027101"},{"Id":407465,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 120/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"62037059705"},{"Id":407466,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 120/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"62037059790"},{"Id":407467,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 180/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"62037059805"},{"Id":407468,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 180/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"62037059890"},{"Id":407469,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 240/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"62037059905"},{"Id":407470,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 240/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"62037059990"},{"Id":407471,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 300/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"62037060005"},{"Id":407472,"FormularyType":"OHP","DrugName":"CARTIA XT CAP 300/24HR","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"62037060090"},{"Id":407473,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 18MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100460","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG","NDC":"62037072501"},{"Id":407474,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"62037072601"},{"Id":407475,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 54MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100480","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","NDC":"62037072701"},{"Id":407476,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 27MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100465","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","NDC":"62037073401"},{"Id":407477,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"62135000237"},{"Id":407478,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"62135000247"},{"Id":407479,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"62135000294"},{"Id":407480,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"62135000337"},{"Id":407481,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"62135000347"},{"Id":407482,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"62135000856"},{"Id":407483,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"62135001047"},{"Id":407484,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"62135001950"},{"Id":407485,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"62135002007"},{"Id":407486,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"62135002021"},{"Id":407487,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"62135002046"},{"Id":407488,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"62135002160"},{"Id":407489,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"62135002201"},{"Id":407490,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"62135002260"},{"Id":407491,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"62135003950"},{"Id":407492,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"62135004190"},{"Id":407493,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"62135004290"},{"Id":407494,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"62135004390"},{"Id":407495,"FormularyType":"OHP","DrugName":"HYDROXYZINE SOL 50/25ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"62135005024"},{"Id":407496,"FormularyType":"OHP","DrugName":"HYDROXYZINE SOL 50/25ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"62135005052"},{"Id":407497,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"62135005190"},{"Id":407498,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"62135005290"},{"Id":407499,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"62135005390"},{"Id":407500,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"62135005490"},{"Id":407501,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"62135005741"},{"Id":407502,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"62135005747"},{"Id":407503,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"62135006718"},{"Id":407504,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"62135006790"},{"Id":407505,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000110","GenericName":"INDOMETHACIN CAP 50 MG","NDC":"62135006818"},{"Id":407506,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000110","GenericName":"INDOMETHACIN CAP 50 MG","NDC":"62135006890"},{"Id":407507,"FormularyType":"OHP","DrugName":"DEXAMETHASON ELX 0.5/5ML","DosageForm":"ELIX - Elixir","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020001005","GenericName":"DEXAMETHASONE ELIXIR 0.5 MG/5ML","NDC":"62135011437"},{"Id":407508,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"62135012130"},{"Id":407509,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"62135012230"},{"Id":407510,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"62135013030"},{"Id":407511,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"62135013130"},{"Id":407512,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"62135013277"},{"Id":407513,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"62135013330"},{"Id":407514,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"62135014118"},{"Id":407515,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"62135014157"},{"Id":407516,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"62135014201"},{"Id":407517,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"62135014210"},{"Id":407518,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"62135014218"},{"Id":407519,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"62135014257"},{"Id":407520,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"62135014401"},{"Id":407521,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"62135014410"},{"Id":407522,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"62135014418"},{"Id":407523,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"62135014457"},{"Id":407524,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"62135014560"},{"Id":407525,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"62135014660"},{"Id":407526,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"62135016060"},{"Id":407527,"FormularyType":"OHP","DrugName":"CORTISONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100015100310","GenericName":"CORTISONE ACETATE TAB 25 MG","NDC":"62135017330"},{"Id":407528,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"62135018660"},{"Id":407529,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"62135018941"},{"Id":407530,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"62135018947"},{"Id":407531,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"62135019122"},{"Id":407532,"FormularyType":"OHP","DrugName":"CALC ACETATE TAB 667MG","DosageForm":"TABS - Tablet","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100320","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG","NDC":"62135019222"},{"Id":407533,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"62135020518"},{"Id":407534,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"62135020590"},{"Id":407535,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"62135020618"},{"Id":407536,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"62135020690"},{"Id":407537,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"62135021001"},{"Id":407538,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"62135021005"},{"Id":407539,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"62135021010"},{"Id":407540,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"62135021072"},{"Id":407541,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"62135021090"},{"Id":407542,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"62135022501"},{"Id":407543,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"62135022560"},{"Id":407544,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"62135023690"},{"Id":407545,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"62135024230"},{"Id":407546,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"62135024260"},{"Id":407547,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"62135024290"},{"Id":407548,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"62135025037"},{"Id":407549,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"62135025047"},{"Id":407550,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000105","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 50 MG","NDC":"62135026001"},{"Id":407551,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"62135026225"},{"Id":407552,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"62135026250"},{"Id":407553,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"62135026260"},{"Id":407554,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"62135026601"},{"Id":407555,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"62135026660"},{"Id":407556,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"62135027101"},{"Id":407557,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"62135027130"},{"Id":407558,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"62135027190"},{"Id":407559,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"62135027201"},{"Id":407560,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"62135027205"},{"Id":407561,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"62135027290"},{"Id":407562,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"62135027301"},{"Id":407563,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"62135027305"},{"Id":407564,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"62135027390"},{"Id":407565,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"62135027401"},{"Id":407566,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"62135027405"},{"Id":407567,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"62135027490"},{"Id":407568,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"62135030801"},{"Id":407569,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"62135030901"},{"Id":407570,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"62135030905"},{"Id":407571,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"62135030920"},{"Id":407572,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"62135030928"},{"Id":407573,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"62135031050"},{"Id":407574,"FormularyType":"OHP","DrugName":"ANAGRELIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85156010100120","GenericName":"ANAGRELIDE HCL CAP 0.5 MG","NDC":"62135031212"},{"Id":407575,"FormularyType":"OHP","DrugName":"ANAGRELIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85156010100130","GenericName":"ANAGRELIDE HCL CAP 1 MG","NDC":"62135031360"},{"Id":407576,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000105","GenericName":"RIFAMPIN CAP 150 MG","NDC":"62135031530"},{"Id":407577,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"62135031660"},{"Id":407578,"FormularyType":"OHP","DrugName":"METHYLDOPA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201030000310","GenericName":"METHYLDOPA TAB 250 MG","NDC":"62135032118"},{"Id":407579,"FormularyType":"OHP","DrugName":"METHYLDOPA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201030000310","GenericName":"METHYLDOPA TAB 250 MG","NDC":"62135032190"},{"Id":407580,"FormularyType":"OHP","DrugName":"METHYLDOPA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201030000315","GenericName":"METHYLDOPA TAB 500 MG","NDC":"62135032218"},{"Id":407581,"FormularyType":"OHP","DrugName":"METHYLDOPA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201030000315","GenericName":"METHYLDOPA TAB 500 MG","NDC":"62135032290"},{"Id":407582,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202040","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 5 MG/5ML (BASE EQUIV)","NDC":"62135033041"},{"Id":407583,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"62135033312"},{"Id":407584,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"62135033412"},{"Id":407585,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"62135033590"},{"Id":407586,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100320","GenericName":"DILTIAZEM HCL TAB 120 MG","NDC":"62135033690"},{"Id":407587,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"62135034011"},{"Id":407588,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"62135034053"},{"Id":407589,"FormularyType":"OHP","DrugName":"SOD POLY SUL POW","DosageForm":"POWD - Powder","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010002900","GenericName":"*SODIUM POLYSTYRENE SULFONATE POWDER**","NDC":"62135034062"},{"Id":407590,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"62135035005"},{"Id":407591,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"62135035030"},{"Id":407592,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"62135035105"},{"Id":407593,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"62135035130"},{"Id":407594,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"62135037290"},{"Id":407595,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"62135040012"},{"Id":407596,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"62135040112"},{"Id":407597,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"62135040212"},{"Id":407598,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"62135042801"},{"Id":407599,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"62135042812"},{"Id":407600,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"62135042960"},{"Id":407601,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"62135043060"},{"Id":407602,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000325","GenericName":"DISULFIRAM TAB 250 MG","NDC":"62135043130"},{"Id":407603,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000325","GenericName":"DISULFIRAM TAB 250 MG","NDC":"62135043190"},{"Id":407604,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000350","GenericName":"DISULFIRAM TAB 500 MG","NDC":"62135043230"},{"Id":407605,"FormularyType":"OHP","DrugName":"DISULFIRAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802040000350","GenericName":"DISULFIRAM TAB 500 MG","NDC":"62135043290"},{"Id":407606,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"62135043447"},{"Id":407607,"FormularyType":"OHP","DrugName":"K CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202022002025","GenericName":"POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML","NDC":"62135043547"},{"Id":407608,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"62135043601"},{"Id":407609,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"62135043690"},{"Id":407610,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"62135043990"},{"Id":407611,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"62135044001"},{"Id":407612,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"62135044031"},{"Id":407613,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"62135044090"},{"Id":407614,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"62135044131"},{"Id":407615,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"62135044160"},{"Id":407616,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"62135044220"},{"Id":407617,"FormularyType":"OHP","DrugName":"NEOMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000040100305","GenericName":"NEOMYCIN SULFATE TAB 500 MG","NDC":"62135044390"},{"Id":407618,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"62135044490"},{"Id":407619,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"62135044590"},{"Id":407620,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"62135044690"},{"Id":407621,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"62135044790"},{"Id":407622,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"62135044805"},{"Id":407623,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"62135044890"},{"Id":407624,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"62135044905"},{"Id":407625,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"62135044990"},{"Id":407626,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000310","GenericName":"ACARBOSE TAB 25 MG","NDC":"62135045390"},{"Id":407627,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000320","GenericName":"ACARBOSE TAB 50 MG","NDC":"62135045490"},{"Id":407628,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000340","GenericName":"ACARBOSE TAB 100 MG","NDC":"62135045590"},{"Id":407629,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"62135045790"},{"Id":407630,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"62135045890"},{"Id":407631,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"62135045990"},{"Id":407632,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"62135046090"},{"Id":407633,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"62135046190"},{"Id":407634,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"62135046220"},{"Id":407635,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"62135046320"},{"Id":407636,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"62135046630"},{"Id":407637,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"62135046890"},{"Id":407638,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"62135047018"},{"Id":407639,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"62135047090"},{"Id":407640,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"62135047118"},{"Id":407641,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"62135047190"},{"Id":407642,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"62135047290"},{"Id":407643,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"62135047305"},{"Id":407644,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"62135047390"},{"Id":407645,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"62135047405"},{"Id":407646,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"62135047490"},{"Id":407647,"FormularyType":"OHP","DrugName":"DANAZOL CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000105","GenericName":"DANAZOL CAP 50 MG","NDC":"62135047560"},{"Id":407648,"FormularyType":"OHP","DrugName":"DANAZOL CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000110","GenericName":"DANAZOL CAP 100 MG","NDC":"62135047660"},{"Id":407649,"FormularyType":"OHP","DrugName":"DANAZOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100005000115","GenericName":"DANAZOL CAP 200 MG","NDC":"62135047760"},{"Id":407650,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"62135048042"},{"Id":407651,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"62135048049"},{"Id":407652,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"62135048142"},{"Id":407653,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"62135048149"},{"Id":407654,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"62135049030"},{"Id":407655,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"62135049090"},{"Id":407656,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"62135049130"},{"Id":407657,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"62135049190"},{"Id":407658,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 500MG","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"62135049790"},{"Id":407659,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"62135049890"},{"Id":407660,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL SYP 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"62135050247"},{"Id":407661,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"62135050330"},{"Id":407662,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"62135050530"},{"Id":407663,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"62135050590"},{"Id":407664,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"62135050630"},{"Id":407665,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"62135050690"},{"Id":407666,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"62135050790"},{"Id":407667,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"62135050890"},{"Id":407668,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"62135050990"},{"Id":407669,"FormularyType":"OHP","DrugName":"HYOSCYAMINE ELX 0.125/5","DosageForm":"ELIX - Elixir","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030101055","GenericName":"HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML","NDC":"62135051147"},{"Id":407670,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"62135051212"},{"Id":407671,"FormularyType":"OHP","DrugName":"HYOSCYAMINE DRO 0.125/ML","DosageForm":"SOLN - Solution","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030102050","GenericName":"HYOSCYAMINE SULFATE SOLN 0.125 MG/ML","NDC":"62135051352"},{"Id":407672,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"62135051631"},{"Id":407673,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"62135051690"},{"Id":407674,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"62135051731"},{"Id":407675,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"62135051790"},{"Id":407676,"FormularyType":"OHP","DrugName":"OXYBUTYNIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045202010","GenericName":"OXYBUTYNIN CHLORIDE SOLUTION 5 MG/5ML","NDC":"62135052005"},{"Id":407677,"FormularyType":"OHP","DrugName":"OXYBUTYNIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045202010","GenericName":"OXYBUTYNIN CHLORIDE SOLUTION 5 MG/5ML","NDC":"62135052024"},{"Id":407678,"FormularyType":"OHP","DrugName":"OXYBUTYNIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045202010","GenericName":"OXYBUTYNIN CHLORIDE SOLUTION 5 MG/5ML","NDC":"62135052047"},{"Id":407679,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"62135052190"},{"Id":407680,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"62135052290"},{"Id":407681,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"62135052390"},{"Id":407682,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"62135052490"},{"Id":407683,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"62135052590"},{"Id":407684,"FormularyType":"OHP","DrugName":"METOCLOPRAM SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102013","GenericName":"METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","NDC":"62135052647"},{"Id":407685,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"62135052741"},{"Id":407686,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"62135052809"},{"Id":407687,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"62135052824"},{"Id":407688,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"62135052845"},{"Id":407689,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"62135052990"},{"Id":407690,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"62135053090"},{"Id":407691,"FormularyType":"OHP","DrugName":"VERAPAMIL CAP 100MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030107015","GenericName":"VERAPAMIL HCL CAP ER 24HR 100 MG","NDC":"62135053230"},{"Id":407692,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"62135053390"},{"Id":407693,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"62135053408"},{"Id":407694,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"62135053490"},{"Id":407695,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"62135053530"},{"Id":407696,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"62135053630"},{"Id":407697,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"62135053730"},{"Id":407698,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"62135054847"},{"Id":407699,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"62135055160"},{"Id":407700,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"62135055290"},{"Id":407701,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"62135055330"},{"Id":407702,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"62135055390"},{"Id":407703,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"62135055558"},{"Id":407704,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"62135055930"},{"Id":407705,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"62135057230"},{"Id":407706,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"62135057290"},{"Id":407707,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"62135057305"},{"Id":407708,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100305","GenericName":"HYDROXYZINE HCL TAB 10 MG","NDC":"62135057312"},{"Id":407709,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"62135057405"},{"Id":407710,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100310","GenericName":"HYDROXYZINE HCL TAB 25 MG","NDC":"62135057412"},{"Id":407711,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"62135057505"},{"Id":407712,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040100315","GenericName":"HYDROXYZINE HCL TAB 50 MG","NDC":"62135057512"},{"Id":407713,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"62135057760"},{"Id":407714,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"62135057912"},{"Id":407715,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"62135058012"},{"Id":407716,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"62135058112"},{"Id":407717,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"62135058212"},{"Id":407718,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000305","GenericName":"GLYBURIDE TAB 1.25 MG","NDC":"62135058330"},{"Id":407719,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"62135058430"},{"Id":407720,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"62135058590"},{"Id":407721,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007520","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","NDC":"62135058690"},{"Id":407722,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007530","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","NDC":"62135058790"},{"Id":407723,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 120MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025007540","GenericName":"ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG","NDC":"62135058890"},{"Id":407724,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"62135058990"},{"Id":407725,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"62135059090"},{"Id":407726,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"62135059190"},{"Id":407727,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"62135059290"},{"Id":407728,"FormularyType":"OHP","DrugName":"PROPYLTHIOUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300020000310","GenericName":"PROPYLTHIOURACIL TAB 50 MG","NDC":"62135060690"},{"Id":407729,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"62135060712"},{"Id":407730,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"62135060812"},{"Id":407731,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"62135060990"},{"Id":407732,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"62135061090"},{"Id":407733,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.5MCG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000110","GenericName":"CALCITRIOL CAP 0.5 MCG","NDC":"62135061190"},{"Id":407734,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"62135061260"},{"Id":407735,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"62135061330"},{"Id":407736,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"62135061390"},{"Id":407737,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"62135061430"},{"Id":407738,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"62135061490"},{"Id":407739,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"62135061560"},{"Id":407740,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000310","GenericName":"CLARITHROMYCIN TAB 250 MG","NDC":"62135061660"},{"Id":407741,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"62135061812"},{"Id":407742,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100302","GenericName":"DOXYCYCLINE HYCLATE TAB 20 MG","NDC":"62135062390"},{"Id":407743,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062601"},{"Id":407744,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062605"},{"Id":407745,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062610"},{"Id":407746,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062612"},{"Id":407747,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062623"},{"Id":407748,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062628"},{"Id":407749,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062631"},{"Id":407750,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062640"},{"Id":407751,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062650"},{"Id":407752,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"62135062696"},{"Id":407753,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"62135063030"},{"Id":407754,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000310","GenericName":"CIMETIDINE TAB 300 MG","NDC":"62135063190"},{"Id":407755,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000315","GenericName":"CIMETIDINE TAB 400 MG","NDC":"62135063290"},{"Id":407756,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000320","GenericName":"CIMETIDINE TAB 800 MG","NDC":"62135063390"},{"Id":407757,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"62135064031"},{"Id":407758,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"62135064090"},{"Id":407759,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"62135064131"},{"Id":407760,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"62135064190"},{"Id":407761,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"62135064231"},{"Id":407762,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"62135064290"},{"Id":407763,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"62135064331"},{"Id":407764,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"62135064390"},{"Id":407765,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"62135064431"},{"Id":407766,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"62135064490"},{"Id":407767,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"62135064531"},{"Id":407768,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"62135064590"},{"Id":407769,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"62135064690"},{"Id":407770,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"62135064790"},{"Id":407771,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"62135064890"},{"Id":407772,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"62135064941"},{"Id":407773,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"62135064947"},{"Id":407774,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"62135065024"},{"Id":407775,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"62135065051"},{"Id":407776,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"62135065514"},{"Id":407777,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"62135065650"},{"Id":407778,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"62135065714"},{"Id":407779,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"62135065890"},{"Id":407780,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"62135065930"},{"Id":407781,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"62135066060"},{"Id":407782,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"62135066160"},{"Id":407783,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"62135066260"},{"Id":407784,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"62135067190"},{"Id":407785,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"62135067290"},{"Id":407786,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"62135067390"},{"Id":407787,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"62135067490"},{"Id":407788,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"62135068005"},{"Id":407789,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"62135068018"},{"Id":407790,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"62135068090"},{"Id":407791,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000335","GenericName":"METFORMIN HCL TAB 750 MG","NDC":"62135068230"},{"Id":407792,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"62135068318"},{"Id":407793,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"62135068330"},{"Id":407794,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"62135068390"},{"Id":407795,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"62135068405"},{"Id":407796,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"62135068418"},{"Id":407797,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"62135068490"},{"Id":407798,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"62135069090"},{"Id":407799,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"62135069190"},{"Id":407800,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"62135069290"},{"Id":407801,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"62135069330"},{"Id":407802,"FormularyType":"OHP","DrugName":"SELEGILINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100320","GenericName":"SELEGILINE HCL TAB 5 MG","NDC":"62135069460"},{"Id":407803,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"62135070451"},{"Id":407804,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"62135070543"},{"Id":407805,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"62135070551"},{"Id":407806,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"62135070552"},{"Id":407807,"FormularyType":"OHP","DrugName":"LAMIVUDINE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060002020","GenericName":"LAMIVUDINE ORAL SOLN 10 MG/ML","NDC":"62135070637"},{"Id":407808,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"62135070990"},{"Id":407809,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"62135071074"},{"Id":407810,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"62135071174"},{"Id":407811,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% ORAL","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"62135071242"},{"Id":407812,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"62135071412"},{"Id":407813,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"62135071460"},{"Id":407814,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"62135071518"},{"Id":407815,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"62135071590"},{"Id":407816,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"62135071618"},{"Id":407817,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"62135071690"},{"Id":407818,"FormularyType":"OHP","DrugName":"CHLOROQUINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000010200310","GenericName":"CHLOROQUINE PHOSPHATE TAB 500 MG","NDC":"62135071726"},{"Id":407819,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"62135071890"},{"Id":407820,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"62135071990"},{"Id":407821,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"62135072090"},{"Id":407822,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"62135072190"},{"Id":407823,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"62135072290"},{"Id":407824,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000305","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 50 MG","NDC":"62135072520"},{"Id":407825,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"62135072620"},{"Id":407826,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"62135072790"},{"Id":407827,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"62135072890"},{"Id":407828,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350320","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG","NDC":"62135073160"},{"Id":407829,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350325","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG","NDC":"62135073260"},{"Id":407830,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350340","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 5-500 MG","NDC":"62135073360"},{"Id":407831,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"62135073890"},{"Id":407832,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000105","GenericName":"NIFEDIPINE CAP 10 MG","NDC":"62135073990"},{"Id":407833,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000110","GenericName":"NIFEDIPINE CAP 20 MG","NDC":"62135074090"},{"Id":407834,"FormularyType":"OHP","DrugName":"NYSTATIN TAB 500000","DosageForm":"TABS - Tablet","Strength":"500000","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000060000305","GenericName":"NYSTATIN TAB 500000 UNIT","NDC":"62135074190"},{"Id":407835,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"62135074260"},{"Id":407836,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100303","GenericName":"VERAPAMIL HCL TAB 40 MG","NDC":"62135074390"},{"Id":407837,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100305","GenericName":"VERAPAMIL HCL TAB 80 MG","NDC":"62135074490"},{"Id":407838,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100310","GenericName":"VERAPAMIL HCL TAB 120 MG","NDC":"62135074590"},{"Id":407839,"FormularyType":"OHP","DrugName":"SMZ-TMP SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"62135074947"},{"Id":407840,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL SYP 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"62135075047"},{"Id":407841,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"62135075290"},{"Id":407842,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"62135075390"},{"Id":407843,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"62135075490"},{"Id":407844,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100310","GenericName":"BETHANECHOL CHLORIDE TAB 5 MG","NDC":"62135075590"},{"Id":407845,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"62135075612"},{"Id":407846,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"62135075712"},{"Id":407847,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100340","GenericName":"BETHANECHOL CHLORIDE TAB 50 MG","NDC":"62135075812"},{"Id":407848,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"62135076001"},{"Id":407849,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"62135076021"},{"Id":407850,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000315","GenericName":"METHYLPREDNISOLONE TAB 8 MG","NDC":"62135076126"},{"Id":407851,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000320","GenericName":"METHYLPREDNISOLONE TAB 16 MG","NDC":"62135076250"},{"Id":407852,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000330","GenericName":"METHYLPREDNISOLONE TAB 32 MG","NDC":"62135076326"},{"Id":407853,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100105","GenericName":"CLINDAMYCIN HCL CAP 75 MG","NDC":"62135076401"},{"Id":407854,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"62135076501"},{"Id":407855,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"62135076601"},{"Id":407856,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"62135076990"},{"Id":407857,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"62135077090"},{"Id":407858,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"62135077190"},{"Id":407859,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"62135077235"},{"Id":407860,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"62135077405"},{"Id":407861,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 12.5/10","DosageForm":"SOLN - Solution","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"62135077410"},{"Id":407862,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 12.5/10","DosageForm":"SOLN - Solution","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"62135077423"},{"Id":407863,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"62135077424"},{"Id":407864,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"62135077441"},{"Id":407865,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"62135077447"},{"Id":407866,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"62135077530"},{"Id":407867,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"62135077590"},{"Id":407868,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"62135077638"},{"Id":407869,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"62135077642"},{"Id":407870,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"62135077668"},{"Id":407871,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"62135077738"},{"Id":407872,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"62135077742"},{"Id":407873,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"62135077768"},{"Id":407874,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"62135077890"},{"Id":407875,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"62135077990"},{"Id":407876,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"62135078130"},{"Id":407877,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"62135078230"},{"Id":407878,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"62135078590"},{"Id":407879,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"62135078930"},{"Id":407880,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"62135078990"},{"Id":407881,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010000105","GenericName":"ETHOSUXIMIDE CAP 250 MG","NDC":"62135079012"},{"Id":407882,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"62135079160"},{"Id":407883,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"62135079260"},{"Id":407884,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"62135079330"},{"Id":407885,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"62135079430"},{"Id":407886,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"62135079590"},{"Id":407887,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"62135079690"},{"Id":407888,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"62135080060"},{"Id":407889,"FormularyType":"OHP","DrugName":"ACETIC ACID SOL 2% OTIC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC AGENTS - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87400010102010","GenericName":"ACETIC ACID OTIC SOLN 2%","NDC":"62135080151"},{"Id":407890,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"62135080224"},{"Id":407891,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"62135080245"},{"Id":407892,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"62135080253"},{"Id":407893,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"62135080347"},{"Id":407894,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"62135080430"},{"Id":407895,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"62135080530"},{"Id":407896,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"62135080630"},{"Id":407897,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"62135080790"},{"Id":407898,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"62135080890"},{"Id":407899,"FormularyType":"OHP","DrugName":"CIMETIDINE SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200010102050","GenericName":"CIMETIDINE HCL SOLN 300 MG/5ML","NDC":"62135080905"},{"Id":407900,"FormularyType":"OHP","DrugName":"CIMETIDINE SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200010102050","GenericName":"CIMETIDINE HCL SOLN 300 MG/5ML","NDC":"62135080924"},{"Id":407901,"FormularyType":"OHP","DrugName":"CIMETIDINE SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200010102050","GenericName":"CIMETIDINE HCL SOLN 300 MG/5ML","NDC":"62135080937"},{"Id":407902,"FormularyType":"OHP","DrugName":"FLUTICASONE SPR 50MCG","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200032301810","GenericName":"FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT","NDC":"62135081061"},{"Id":407903,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"O","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"62135081346"},{"Id":407904,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"O","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"62135081347"},{"Id":407905,"FormularyType":"OHP","DrugName":"CICLOPIROX SOL 8%","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030002020","GenericName":"CICLOPIROX SOLUTION 8%","NDC":"62135081445"},{"Id":407906,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200105","GenericName":"HYDROXYZINE PAMOATE CAP 25 MG","NDC":"62135081612"},{"Id":407907,"FormularyType":"OHP","DrugName":"HYDROXYZ PAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040200110","GenericName":"HYDROXYZINE PAMOATE CAP 50 MG","NDC":"62135081712"},{"Id":407908,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"62135081890"},{"Id":407909,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"62135081990"},{"Id":407910,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"62135082090"},{"Id":407911,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"62135082190"},{"Id":407912,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"62135082284"},{"Id":407913,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"62135082384"},{"Id":407914,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"62135082401"},{"Id":407915,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"62135082505"},{"Id":407916,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"62135082560"},{"Id":407917,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"62135082684"},{"Id":407918,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"62135082784"},{"Id":407919,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"62135082884"},{"Id":407920,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.5%","DosageForm":"NEBU - Nebulization solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102520","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)","NDC":"62135082984"},{"Id":407921,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"62135083084"},{"Id":407922,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"62135083184"},{"Id":407923,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"62135083284"},{"Id":407924,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"62135083384"},{"Id":407925,"FormularyType":"OHP","DrugName":"METRONIDAZOL CAP 375MG","DosageForm":"CAPS - Capsule","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000107","GenericName":"METRONIDAZOLE CAP 375 MG","NDC":"62135083650"},{"Id":407926,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"62135083790"},{"Id":407927,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"62135083890"},{"Id":407928,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"62135084154"},{"Id":407929,"FormularyType":"OHP","DrugName":"SULFADIAZINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"SULFONAMIDES","DrugSubClass":"SULFONAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"08000020000305","GenericName":"SULFADIAZINE TAB 500 MG","NDC":"62135084260"},{"Id":407930,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"62135084790"},{"Id":407931,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"62135084890"},{"Id":407932,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"62135084990"},{"Id":407933,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"62135085090"},{"Id":407934,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107220","GenericName":"HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","NDC":"62135085812"},{"Id":407935,"FormularyType":"OHP","DrugName":"HYOSCYAMINE SUB 0.125MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100710","GenericName":"HYOSCYAMINE SULFATE SL TAB 0.125 MG","NDC":"62135085912"},{"Id":407936,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.375 ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0.375","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107420","GenericName":"HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","NDC":"62135086060"},{"Id":407937,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 200/10ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"62135086724"},{"Id":407938,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 200/10ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"62135086759"},{"Id":407939,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"62135086824"},{"Id":407940,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"62135086851"},{"Id":407941,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"62135086924"},{"Id":407942,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"62135086943"},{"Id":407943,"FormularyType":"OHP","DrugName":"SMZ-TMP SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"62135087324"},{"Id":407944,"FormularyType":"OHP","DrugName":"SMZ-TMP SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"62135087352"},{"Id":407945,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"62135088030"},{"Id":407946,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"62135088130"},{"Id":407947,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"62135088230"},{"Id":407948,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010007520","GenericName":"CLARITHROMYCIN TAB ER 24HR 500 MG","NDC":"62135088360"},{"Id":407949,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"62135088505"},{"Id":407950,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"62135088510"},{"Id":407951,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"62135088522"},{"Id":407952,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"62135088523"},{"Id":407953,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 50MG/5ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"62135088524"},{"Id":407954,"FormularyType":"OHP","DrugName":"GENERLAC SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"62135089247"},{"Id":407955,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"62135089390"},{"Id":407956,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"62135089490"},{"Id":407957,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"62135089560"},{"Id":407958,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"62135089660"},{"Id":407959,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"62135089718"},{"Id":407960,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"62135089790"},{"Id":407961,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"62135089818"},{"Id":407962,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"62135089890"},{"Id":407963,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"62135089990"},{"Id":407964,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"62135090060"},{"Id":407965,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"62135090160"},{"Id":407966,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"62135090260"},{"Id":407967,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"62135090360"},{"Id":407968,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000310","GenericName":"ETODOLAC TAB 400 MG","NDC":"62135091060"},{"Id":407969,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000320","GenericName":"ETODOLAC TAB 500 MG","NDC":"62135091160"},{"Id":407970,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"62135092760"},{"Id":407971,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"62135092860"},{"Id":407972,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"62135093060"},{"Id":407973,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"62135093754"},{"Id":407974,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"62135094947"},{"Id":407975,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"62135094994"},{"Id":407976,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"62135095290"},{"Id":407977,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"62135095390"},{"Id":407978,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"62135096001"},{"Id":407979,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"62135096005"},{"Id":407980,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"62135096010"},{"Id":407981,"FormularyType":"OHP","DrugName":"SULFASALAZIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500060000310","GenericName":"SULFASALAZINE TAB 500 MG","NDC":"62135096031"},{"Id":407982,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"62135096247"},{"Id":407983,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"62135096530"},{"Id":407984,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"62135096630"},{"Id":407985,"FormularyType":"OHP","DrugName":"GRISEOFULVIN SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000030101805","GenericName":"GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML","NDC":"62135096841"},{"Id":407986,"FormularyType":"OHP","DrugName":"MEFLOQUINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000025100310","GenericName":"MEFLOQUINE HCL TAB 250 MG","NDC":"62135097325"},{"Id":407987,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"62135097630"},{"Id":407988,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"62135097690"},{"Id":407989,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"62135097730"},{"Id":407990,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"62135097790"},{"Id":407991,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"62135097830"},{"Id":407992,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"62135097890"},{"Id":407993,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000320","GenericName":"CILOSTAZOL TAB 50 MG","NDC":"62135098360"},{"Id":407994,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"62135098405"},{"Id":407995,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"62135098450"},{"Id":407996,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"62135098505"},{"Id":407997,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"62135098550"},{"Id":407998,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000330","GenericName":"CILOSTAZOL TAB 100 MG","NDC":"62135098660"},{"Id":407999,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"62175011432"},{"Id":408000,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"62175011437"},{"Id":408001,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"62175011832"},{"Id":408002,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"62175011837"},{"Id":408003,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"62175011843"},{"Id":408004,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"62175013232"},{"Id":408005,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"62175013632"},{"Id":408006,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"62175013637"},{"Id":408007,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"62175013643"},{"Id":408008,"FormularyType":"OHP","DrugName":"GLYCOLAX POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"62175019015"},{"Id":408009,"FormularyType":"OHP","DrugName":"GLYCOLAX POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"62175019031"},{"Id":408010,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"62175020443"},{"Id":408011,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"62175020446"},{"Id":408012,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"62175020532"},{"Id":408013,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"62175020543"},{"Id":408014,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"62175020546"},{"Id":408015,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"62175026037"},{"Id":408016,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"62175026046"},{"Id":408017,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"62175026055"},{"Id":408018,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"62175026137"},{"Id":408019,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"62175026146"},{"Id":408020,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"62175026155"},{"Id":408021,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"62175026232"},{"Id":408022,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"62175026237"},{"Id":408023,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"62175026246"},{"Id":408024,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"62175027037"},{"Id":408025,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"62175027041"},{"Id":408026,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"62175027137"},{"Id":408027,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"62175027141"},{"Id":408028,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"62175027237"},{"Id":408029,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"62175027241"},{"Id":408030,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"62175030232"},{"Id":408031,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"62175030243"},{"Id":408032,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"62175030246"},{"Id":408033,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 500MG ER","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"62175032046"},{"Id":408034,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"62175032246"},{"Id":408035,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"62175038037"},{"Id":408036,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"62175038237"},{"Id":408037,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"62175045232"},{"Id":408038,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"62175045832"},{"Id":408039,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"62175061743"},{"Id":408040,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"62175061746"},{"Id":408041,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"62175061846"},{"Id":408042,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"62175082032"},{"Id":408043,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"62175082043"},{"Id":408044,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"62175082046"},{"Id":408045,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"62175084032"},{"Id":408046,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"62175084043"},{"Id":408047,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"62175084046"},{"Id":408048,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"62250067630"},{"Id":408049,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"62250080208"},{"Id":408050,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"62332000131"},{"Id":408051,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"62332000191"},{"Id":408052,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"62332000231"},{"Id":408053,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"62332000271"},{"Id":408054,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"62332000291"},{"Id":408055,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"62332001631"},{"Id":408056,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"62332001671"},{"Id":408057,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"62332001731"},{"Id":408058,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"62332001771"},{"Id":408059,"FormularyType":"OHP","DrugName":"METRONIDAZOL CAP 375MG","DosageForm":"CAPS - Capsule","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000107","GenericName":"METRONIDAZOLE CAP 375 MG","NDC":"62332001850"},{"Id":408060,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"62332002531"},{"Id":408061,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"62332002631"},{"Id":408062,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"62332002730"},{"Id":408063,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"62332002790"},{"Id":408064,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"62332002791"},{"Id":408065,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"62332002830"},{"Id":408066,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"62332002890"},{"Id":408067,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"62332002891"},{"Id":408068,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"62332002930"},{"Id":408069,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"62332002990"},{"Id":408070,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"62332002991"},{"Id":408071,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"62332003031"},{"Id":408072,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"62332003131"},{"Id":408073,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"62332003231"},{"Id":408074,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"62332003331"},{"Id":408075,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100337","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 3 MG","NDC":"62332003431"},{"Id":408076,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100344","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 4 MG","NDC":"62332003531"},{"Id":408077,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100350","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 5 MG","NDC":"62332003631"},{"Id":408078,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"62332004130"},{"Id":408079,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"62332004190"},{"Id":408080,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"62332004230"},{"Id":408081,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"62332004271"},{"Id":408082,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"62332004290"},{"Id":408083,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"62332004330"},{"Id":408084,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"62332004371"},{"Id":408085,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"62332004390"},{"Id":408086,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"62332004430"},{"Id":408087,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"62332004490"},{"Id":408088,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"62332004571"},{"Id":408089,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"62332004590"},{"Id":408090,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"62332004671"},{"Id":408091,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"62332004690"},{"Id":408092,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"62332004771"},{"Id":408093,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"62332004790"},{"Id":408094,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"62332004830"},{"Id":408095,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"62332004890"},{"Id":408096,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"62332004891"},{"Id":408097,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"62332004930"},{"Id":408098,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"62332004990"},{"Id":408099,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"62332004991"},{"Id":408100,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"62332005030"},{"Id":408101,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"62332005090"},{"Id":408102,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"62332005091"},{"Id":408103,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"62332005130"},{"Id":408104,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 150-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300320","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","NDC":"62332005190"},{"Id":408105,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"62332005230"},{"Id":408106,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"62332005290"},{"Id":408107,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"62332005431"},{"Id":408108,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"62332005471"},{"Id":408109,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"62332005491"},{"Id":408110,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"62332005531"},{"Id":408111,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"62332005571"},{"Id":408112,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"62332005591"},{"Id":408113,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"62332005631"},{"Id":408114,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"62332005671"},{"Id":408115,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"62332006030"},{"Id":408116,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"62332006090"},{"Id":408117,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"62332006130"},{"Id":408118,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"62332006230"},{"Id":408119,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"62332006360"},{"Id":408120,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"62332006460"},{"Id":408121,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"62332006560"},{"Id":408122,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"62332006660"},{"Id":408123,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"62332007531"},{"Id":408124,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"62332007560"},{"Id":408125,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"62332007591"},{"Id":408126,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"62332007631"},{"Id":408127,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"62332007642"},{"Id":408128,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"62332007660"},{"Id":408129,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"62332007671"},{"Id":408130,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"62332007971"},{"Id":408131,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"62332007990"},{"Id":408132,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"62332008071"},{"Id":408133,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"62332008090"},{"Id":408134,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"62332008171"},{"Id":408135,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"62332008190"},{"Id":408136,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"62332008271"},{"Id":408137,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"62332008290"},{"Id":408138,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"62332008371"},{"Id":408139,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"62332008390"},{"Id":408140,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"62332008431"},{"Id":408141,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"62332008531"},{"Id":408142,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"62332008631"},{"Id":408143,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"62332008730"},{"Id":408144,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"62332008830"},{"Id":408145,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"62332008930"},{"Id":408146,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"62332009230"},{"Id":408147,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"62332009290"},{"Id":408148,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"62332009291"},{"Id":408149,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"62332009330"},{"Id":408150,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"62332009390"},{"Id":408151,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"62332009391"},{"Id":408152,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"62332011231"},{"Id":408153,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"62332011291"},{"Id":408154,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"62332011331"},{"Id":408155,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"62332011391"},{"Id":408156,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"62332011431"},{"Id":408157,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"62332011491"},{"Id":408158,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200310","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","NDC":"62332011531"},{"Id":408159,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200320","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"62332011631"},{"Id":408160,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"62332011990"},{"Id":408161,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"62332012090"},{"Id":408162,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"62332012190"},{"Id":408163,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"62332012290"},{"Id":408164,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"62332012390"},{"Id":408165,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"62332012490"},{"Id":408166,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"62332012590"},{"Id":408167,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"62332012690"},{"Id":408168,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"62332013130"},{"Id":408169,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"62332013190"},{"Id":408170,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"62332013230"},{"Id":408171,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"62332013290"},{"Id":408172,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"62332013330"},{"Id":408173,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"62332013390"},{"Id":408174,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"62332014131"},{"Id":408175,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"62332014171"},{"Id":408176,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"62332014231"},{"Id":408177,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"62332014271"},{"Id":408178,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"62332014291"},{"Id":408179,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"62332014930"},{"Id":408180,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"62332014990"},{"Id":408181,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"62332015030"},{"Id":408182,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"62332015090"},{"Id":408183,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"62332015130"},{"Id":408184,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"62332015190"},{"Id":408185,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"62332017160"},{"Id":408186,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"62332017260"},{"Id":408187,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"62332017360"},{"Id":408188,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"62332017460"},{"Id":408189,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"62332018320"},{"Id":408190,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"62332019030"},{"Id":408191,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"62332019130"},{"Id":408192,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"62332019230"},{"Id":408193,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"62332019290"},{"Id":408194,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"62332019330"},{"Id":408195,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"62332019390"},{"Id":408196,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"62332020404"},{"Id":408197,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"62332020430"},{"Id":408198,"FormularyType":"OHP","DrugName":"FENOFIBRIC CAP 45MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200006006520","GenericName":"CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV)","NDC":"62332024490"},{"Id":408199,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"62332024631"},{"Id":408200,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"62332024671"},{"Id":408201,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"62332025050"},{"Id":408202,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"62332025118"},{"Id":408203,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"62332025130"},{"Id":408204,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"62332025209"},{"Id":408205,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"62332025230"},{"Id":408206,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000340","GenericName":"AZITHROMYCIN TAB 600 MG","NDC":"62332025330"},{"Id":408207,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 125MG","DosageForm":"TBSO - Tablet Soluble","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007320","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 125 MG","NDC":"62332032430"},{"Id":408208,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 250MG","DosageForm":"TBSO - Tablet Soluble","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007330","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 250 MG","NDC":"62332032530"},{"Id":408209,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 500MG","DosageForm":"TBSO - Tablet Soluble","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007340","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 500 MG","NDC":"62332032630"},{"Id":408210,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"62332033831"},{"Id":408211,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"62332033931"},{"Id":408212,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"62332034031"},{"Id":408213,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100310","GenericName":"CANDESARTAN CILEXETIL TAB 4 MG","NDC":"62332034130"},{"Id":408214,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100310","GenericName":"CANDESARTAN CILEXETIL TAB 4 MG","NDC":"62332034190"},{"Id":408215,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"62332034230"},{"Id":408216,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100320","GenericName":"CANDESARTAN CILEXETIL TAB 8 MG","NDC":"62332034290"},{"Id":408217,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"62332034330"},{"Id":408218,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"62332034390"},{"Id":408219,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000310","GenericName":"CLARITHROMYCIN TAB 250 MG","NDC":"62332034460"},{"Id":408220,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"62332034560"},{"Id":408221,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"62332034931"},{"Id":408222,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100302","GenericName":"DOXYCYCLINE HYCLATE TAB 20 MG","NDC":"62332035231"},{"Id":408223,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"62332036071"},{"Id":408224,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"62332036090"},{"Id":408225,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"62332036171"},{"Id":408226,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"62332036190"},{"Id":408227,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"62332036250"},{"Id":408228,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"62332036350"},{"Id":408229,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"62332036371"},{"Id":408230,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100110","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG","NDC":"62332038931"},{"Id":408231,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"62332039031"},{"Id":408232,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"62332039131"},{"Id":408233,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"62332040231"},{"Id":408234,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"62332040331"},{"Id":408235,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"62332040431"},{"Id":408236,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"62332041030"},{"Id":408237,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"62332041130"},{"Id":408238,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"62332041230"},{"Id":408239,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"62332041310"},{"Id":408240,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"62332041410"},{"Id":408241,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"62332041510"},{"Id":408242,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"62332042631"},{"Id":408243,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"62332042671"},{"Id":408244,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"62332042731"},{"Id":408245,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"62332042771"},{"Id":408246,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"62332046206"},{"Id":408247,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"62332046303"},{"Id":408248,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 50000","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"62332046431"},{"Id":408249,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"62332046515"},{"Id":408250,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"62332046530"},{"Id":408251,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"62332046545"},{"Id":408252,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"62332046560"},{"Id":408253,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"62332047831"},{"Id":408254,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"62332047964"},{"Id":408255,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"62332047990"},{"Id":408256,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"62332048090"},{"Id":408257,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"62332048625"},{"Id":408258,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"62332048650"},{"Id":408259,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"62332050203"},{"Id":408260,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"62332050503"},{"Id":408261,"FormularyType":"OHP","DrugName":"AZELASTINE DRO 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802006102020","GenericName":"AZELASTINE HCL OPHTH SOLN 0.05%","NDC":"62332050606"},{"Id":408262,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"62332050705"},{"Id":408263,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"62332050725"},{"Id":408264,"FormularyType":"OHP","DrugName":"TOBRAMYCIN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101070002005","GenericName":"TOBRAMYCIN OPHTH SOLN 0.3%","NDC":"62332051805"},{"Id":408265,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"62332051910"},{"Id":408266,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"62332053231"},{"Id":408267,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"62332053331"},{"Id":408268,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"62332053431"},{"Id":408269,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"62332053890"},{"Id":408270,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"62332053990"},{"Id":408271,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"62332053991"},{"Id":408272,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"62332054505"},{"Id":408273,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"62332054715"},{"Id":408274,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"62332054730"},{"Id":408275,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"62332054745"},{"Id":408276,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"62332054760"},{"Id":408277,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"62332055310"},{"Id":408278,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"62332055490"},{"Id":408279,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"62332055590"},{"Id":408280,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"62332055591"},{"Id":408281,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"62332055645"},{"Id":408282,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"62332055660"},{"Id":408283,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"62332055745"},{"Id":408284,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"62332055760"},{"Id":408285,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"62332055845"},{"Id":408286,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"62332055860"},{"Id":408287,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"62332056530"},{"Id":408288,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"62332056630"},{"Id":408289,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"62332056730"},{"Id":408290,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"62332058204"},{"Id":408291,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"62332058231"},{"Id":408292,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"62332058515"},{"Id":408293,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"62332058530"},{"Id":408294,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"62332058560"},{"Id":408295,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"62332058631"},{"Id":408296,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"62332060330"},{"Id":408297,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"62332060331"},{"Id":408298,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"62332060430"},{"Id":408299,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"62332060431"},{"Id":408300,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"62332060615"},{"Id":408301,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"62332060630"},{"Id":408302,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"62332060660"},{"Id":408303,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000105","GenericName":"CYCLOPHOSPHAMIDE CAP 25 MG","NDC":"62332061831"},{"Id":408304,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000110","GenericName":"CYCLOPHOSPHAMIDE CAP 50 MG","NDC":"62332061931"},{"Id":408305,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"62332062330"},{"Id":408306,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"62332062360"},{"Id":408307,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"62332063406"},{"Id":408308,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"62332063460"},{"Id":408309,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"62332063506"},{"Id":408310,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"62332063560"},{"Id":408311,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"62332063606"},{"Id":408312,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"62332063660"},{"Id":408313,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"62332065403"},{"Id":408314,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"62332065409"},{"Id":408315,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"62332065701"},{"Id":408316,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"62332065705"},{"Id":408317,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"62332067631"},{"Id":408318,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"62332067731"},{"Id":408319,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100320","GenericName":"IVABRADINE HCL TAB 5 MG (BASE EQUIV)","NDC":"62332067960"},{"Id":408320,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100330","GenericName":"IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","NDC":"62332068060"},{"Id":408321,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"62332069131"},{"Id":408322,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"62332069191"},{"Id":408323,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"62332069231"},{"Id":408324,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"62332069291"},{"Id":408325,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"62332069331"},{"Id":408326,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"62332069361"},{"Id":408327,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"62332072435"},{"Id":408328,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"62332073031"},{"Id":408329,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"62332073036"},{"Id":408330,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000110","GenericName":"ACITRETIN CAP 10 MG","NDC":"62332074130"},{"Id":408331,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 17.5MG","DosageForm":"CAPS - Capsule","Strength":"17.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000115","GenericName":"ACITRETIN CAP 17.5 MG","NDC":"62332074230"},{"Id":408332,"FormularyType":"OHP","DrugName":"ACITRETIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250510000125","GenericName":"ACITRETIN CAP 25 MG","NDC":"62332074330"},{"Id":408333,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"62332074905"},{"Id":408334,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"62332074910"},{"Id":408335,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"62332074915"},{"Id":408336,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"62332078131"},{"Id":408337,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"62332078231"},{"Id":408338,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"62332078331"},{"Id":408339,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100320","GenericName":"DILTIAZEM HCL TAB 120 MG","NDC":"62332078431"},{"Id":408340,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"62332080920"},{"Id":408341,"FormularyType":"OHP","DrugName":"TRETINOIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050030003703","GenericName":"TRETINOIN CREAM 0.025%","NDC":"62332080945"},{"Id":408342,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"62332081531"},{"Id":408343,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"62332081631"},{"Id":408344,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"62332081731"},{"Id":408345,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"62379000506"},{"Id":408346,"FormularyType":"OHP","DrugName":"XROMI SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"AGENTS FOR SICKLE CELL DISEASE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"82803030002020","GenericName":"HYDROXYUREA ORAL SOLN 100 MG/ML","NDC":"62484001504"},{"Id":408347,"FormularyType":"OHP","DrugName":"XROMI SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"AGENTS FOR SICKLE CELL DISEASE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"82803030002020","GenericName":"HYDROXYUREA ORAL SOLN 100 MG/ML","NDC":"62484001505"},{"Id":408348,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 2600UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006703","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 2600-8800-15200 UNIT","NDC":"62541040110"},{"Id":408349,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 4200UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006710","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 4200-14200-24600 UNIT","NDC":"62541040210"},{"Id":408350,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 10500UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006734","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10500-35500-61500 UNIT","NDC":"62541040310"},{"Id":408351,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 16800UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006750","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 16800-56800-98400 UNIT","NDC":"62541040410"},{"Id":408352,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 21000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006754","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 21000-54700-83900 UNIT","NDC":"62541040510"},{"Id":408353,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 37000","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006781","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 37000-97300-149900 UNIT","NDC":"62541040610"},{"Id":408354,"FormularyType":"OHP","DrugName":"PANCREAZE CAP 37000","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006781","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 37000-97300-149900 UNIT","NDC":"62541040650"},{"Id":408355,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000505","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***","NDC":"62542020030"},{"Id":408356,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000510","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***","NDC":"62542030030"},{"Id":408357,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000520","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","NDC":"62542040030"},{"Id":408358,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"62559013807"},{"Id":408359,"FormularyType":"OHP","DrugName":"HYDROCORT ENE 100MG","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"INTRARECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89150010005110","GenericName":"HYDROCORTISONE ENEMA 100 MG/60ML","NDC":"62559013811"},{"Id":408360,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"62559015116"},{"Id":408361,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"62559015710"},{"Id":408362,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"62559015730"},{"Id":408363,"FormularyType":"OHP","DrugName":"METOCLOPRAM SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102013","GenericName":"METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","NDC":"62559019016"},{"Id":408364,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"62559022001"},{"Id":408365,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"62559022101"},{"Id":408366,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"62559022105"},{"Id":408367,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"62559022201"},{"Id":408368,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"62559022205"},{"Id":408369,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000320","GenericName":"PROPAFENONE HCL TAB 150 MG","NDC":"62559023001"},{"Id":408370,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000325","GenericName":"PROPAFENONE HCL TAB 225 MG","NDC":"62559023101"},{"Id":408371,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000330","GenericName":"PROPAFENONE HCL TAB 300 MG","NDC":"62559023201"},{"Id":408372,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000303","GenericName":"METHAZOLAMIDE TAB 25 MG","NDC":"62559024001"},{"Id":408373,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000305","GenericName":"METHAZOLAMIDE TAB 50 MG","NDC":"62559024101"},{"Id":408374,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000120","GenericName":"ETODOLAC CAP 200 MG","NDC":"62559025001"},{"Id":408375,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000130","GenericName":"ETODOLAC CAP 300 MG","NDC":"62559025101"},{"Id":408376,"FormularyType":"OHP","DrugName":"ACEBUTOLOL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200010100105","GenericName":"ACEBUTOLOL HCL CAP 200 MG","NDC":"62559025501"},{"Id":408377,"FormularyType":"OHP","DrugName":"ACEBUTOLOL CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200010100110","GenericName":"ACEBUTOLOL HCL CAP 400 MG","NDC":"62559025601"},{"Id":408378,"FormularyType":"OHP","DrugName":"TRANEX ACID TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"HEMOSTATICS","DrugSubClass":"HEMOSTATICS - SYSTEMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"84100040000320","GenericName":"TRANEXAMIC ACID TAB 650 MG","NDC":"62559026530"},{"Id":408379,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"62559029101"},{"Id":408380,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"62559029201"},{"Id":408381,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"62559029501"},{"Id":408382,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"62559029601"},{"Id":408383,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"62559031510"},{"Id":408384,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"62559031610"},{"Id":408385,"FormularyType":"OHP","DrugName":"KIONEX SUS 15GM/60","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001805","GenericName":"SODIUM POLYSTYRENE SULFONATE SUSP 15 GM/60ML","NDC":"62559035601"},{"Id":408386,"FormularyType":"OHP","DrugName":"KIONEX SUS 15GM/60","DosageForm":"SUSP - Suspension","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"POTASSIUM REMOVING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99450010001805","GenericName":"SODIUM POLYSTYRENE SULFONATE SUSP 15 GM/60ML","NDC":"62559035660"},{"Id":408387,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"62559038001"},{"Id":408388,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"62559038101"},{"Id":408389,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"62559038201"},{"Id":408390,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"62559039020"},{"Id":408391,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"62559039050"},{"Id":408392,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"62559039120"},{"Id":408393,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"62559039150"},{"Id":408394,"FormularyType":"OHP","DrugName":"COLESTIPOL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020100320","GenericName":"COLESTIPOL HCL TAB 1 GM","NDC":"62559039512"},{"Id":408395,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150310","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"62559041401"},{"Id":408396,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150320","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"62559041501"},{"Id":408397,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150330","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"62559041601"},{"Id":408398,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150340","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"62559041701"},{"Id":408399,"FormularyType":"OHP","DrugName":"MESALAMINE ENE 4GM","DosageForm":"ENEM - Enema","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005105","GenericName":"MESALAMINE ENEMA 4 GM","NDC":"62559042007"},{"Id":408400,"FormularyType":"OHP","DrugName":"MESALAMINE ENE 4GM","DosageForm":"ENEM - Enema","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005105","GenericName":"MESALAMINE ENEMA 4 GM","NDC":"62559042011"},{"Id":408401,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"62559042101"},{"Id":408402,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107220","GenericName":"HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","NDC":"62559042201"},{"Id":408403,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.375 ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0.375","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107420","GenericName":"HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","NDC":"62559042301"},{"Id":408404,"FormularyType":"OHP","DrugName":"HYOSCYAMINE SUB 0.125MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100710","GenericName":"HYOSCYAMINE SULFATE SL TAB 0.125 MG","NDC":"62559042401"},{"Id":408405,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"M","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"RECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89100010003705","GenericName":"HYDROCORTISONE PERIANAL CREAM 1%","NDC":"62559043001"},{"Id":408406,"FormularyType":"OHP","DrugName":"HYDROCORTISO CRE 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"RECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89100010003720","GenericName":"HYDROCORTISONE PERIANAL CREAM 2.5%","NDC":"62559043130"},{"Id":408407,"FormularyType":"OHP","DrugName":"PYRIDOSTIGM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100305","GenericName":"PYRIDOSTIGMINE BROMIDE TAB 60 MG","NDC":"62559047001"},{"Id":408408,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"62559049001"},{"Id":408409,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"62559049010"},{"Id":408410,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000303","GenericName":"INDAPAMIDE TAB 1.25 MG","NDC":"62559051001"},{"Id":408411,"FormularyType":"OHP","DrugName":"INDAPAMIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600050000305","GenericName":"INDAPAMIDE TAB 2.5 MG","NDC":"62559051101"},{"Id":408412,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000305","GenericName":"PINDOLOL TAB 5 MG","NDC":"62559056001"},{"Id":408413,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000310","GenericName":"PINDOLOL TAB 10 MG","NDC":"62559056101"},{"Id":408414,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 16-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200320","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG","NDC":"62559066090"},{"Id":408415,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200340","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG","NDC":"62559066190"},{"Id":408416,"FormularyType":"OHP","DrugName":"CANDESA/HCTZ TAB 32-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002200350","GenericName":"CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-25 MG","NDC":"62559066290"},{"Id":408417,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200305","GenericName":"TERBUTALINE SULFATE TAB 2.5 MG","NDC":"62559072101"},{"Id":408418,"FormularyType":"OHP","DrugName":"TERBUTALINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201060200310","GenericName":"TERBUTALINE SULFATE TAB 5 MG","NDC":"62559072201"},{"Id":408419,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"62559073001"},{"Id":408420,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"62559073101"},{"Id":408421,"FormularyType":"OHP","DrugName":"THYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"62559074001"},{"Id":408422,"FormularyType":"OHP","DrugName":"THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"62559074101"},{"Id":408423,"FormularyType":"OHP","DrugName":"THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"62559074201"},{"Id":408424,"FormularyType":"OHP","DrugName":"THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"62559074301"},{"Id":408425,"FormularyType":"OHP","DrugName":"THYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"62559074401"},{"Id":408426,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"62559082001"},{"Id":408427,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"62559082101"},{"Id":408428,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"62559082201"},{"Id":408429,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 250/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"62559083003"},{"Id":408430,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 250/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"62559083055"},{"Id":408431,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 250/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"62559083080"},{"Id":408432,"FormularyType":"OHP","DrugName":"BICALUTAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402420000320","GenericName":"BICALUTAMIDE TAB 50 MG","NDC":"62559089030"},{"Id":408433,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"62559099030"},{"Id":408434,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"62559099130"},{"Id":408435,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"62559099212"},{"Id":408436,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"62559099330"},{"Id":408437,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"62756001640"},{"Id":408438,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102010","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML","NDC":"62756001740"},{"Id":408439,"FormularyType":"OHP","DrugName":"EPOPROSTENOL INJ 0.5MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170040102110","GenericName":"EPOPROSTENOL SODIUM FOR INJ 0.5 MG","NDC":"62756005940"},{"Id":408440,"FormularyType":"OHP","DrugName":"EPOPROSTENOL INJ 1.5MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170040102130","GenericName":"EPOPROSTENOL SODIUM FOR INJ 1.5 MG","NDC":"62756006040"},{"Id":408441,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"62756009040"},{"Id":408442,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"62756009045"},{"Id":408443,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2515003510E620","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML","NDC":"62756009140"},{"Id":408444,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"62756013001"},{"Id":408445,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"62756013101"},{"Id":408446,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"62756013702"},{"Id":408447,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"62756013704"},{"Id":408448,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"62756013705"},{"Id":408449,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"62756013802"},{"Id":408450,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"62756013804"},{"Id":408451,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"62756013805"},{"Id":408452,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"62756013902"},{"Id":408453,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"62756013904"},{"Id":408454,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"62756013905"},{"Id":408455,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"62756014201"},{"Id":408456,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"62756014202"},{"Id":408457,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"62756014301"},{"Id":408458,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"62756014513"},{"Id":408459,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"62756014586"},{"Id":408460,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"62756014613"},{"Id":408461,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"62756014686"},{"Id":408462,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"62756014713"},{"Id":408463,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"62756014786"},{"Id":408464,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"62756014813"},{"Id":408465,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"62756014886"},{"Id":408466,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"62756016013"},{"Id":408467,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"62756016081"},{"Id":408468,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"62756016088"},{"Id":408469,"FormularyType":"OHP","DrugName":"DESMOPRESSIN SPR 0.01%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010122010","GenericName":"DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED)","NDC":"62756016191"},{"Id":408470,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"62756018313"},{"Id":408471,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"62756018318"},{"Id":408472,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"62756018388"},{"Id":408473,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"62756018413"},{"Id":408474,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"62756018418"},{"Id":408475,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"62756018488"},{"Id":408476,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"62756018513"},{"Id":408477,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"62756018518"},{"Id":408478,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"62756018588"},{"Id":408479,"FormularyType":"OHP","DrugName":"TIAGABINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170070100302","GenericName":"TIAGABINE HCL TAB 2 MG","NDC":"62756020083"},{"Id":408480,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"62756020201"},{"Id":408481,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"62756020203"},{"Id":408482,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"62756020401"},{"Id":408483,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"62756020403"},{"Id":408484,"FormularyType":"OHP","DrugName":"TIAGABINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170070100305","GenericName":"TIAGABINE HCL TAB 4 MG","NDC":"62756022483"},{"Id":408485,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"62756023886"},{"Id":408486,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"62756023920"},{"Id":408487,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"62756024064"},{"Id":408488,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"62756025802"},{"Id":408489,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"62756025902"},{"Id":408490,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"62756026002"},{"Id":408491,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"62756029313"},{"Id":408492,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"62756029388"},{"Id":408493,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"62756029413"},{"Id":408494,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"62756029488"},{"Id":408495,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200120","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 200 MG","NDC":"62756029983"},{"Id":408496,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200120","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 200 MG","NDC":"62756029988"},{"Id":408497,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"62756035664"},{"Id":408498,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"62756035666"},{"Id":408499,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200320","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"62756036888"},{"Id":408500,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 100-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200325","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG","NDC":"62756036988"},{"Id":408501,"FormularyType":"OHP","DrugName":"METOPRL/HCTZ TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002200310","GenericName":"METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","NDC":"62756037088"},{"Id":408502,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"62756042790"},{"Id":408503,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"62756042986"},{"Id":408504,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200130","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 300 MG","NDC":"62756043283"},{"Id":408505,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200130","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 300 MG","NDC":"62756043288"},{"Id":408506,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"62756045788"},{"Id":408507,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"62756045983"},{"Id":408508,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"62756046083"},{"Id":408509,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"62756046188"},{"Id":408510,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"62756051240"},{"Id":408511,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"62756051244"},{"Id":408512,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"62756051713"},{"Id":408513,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"62756051788"},{"Id":408514,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"62756051813"},{"Id":408515,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"62756051818"},{"Id":408516,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"62756051888"},{"Id":408517,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"62756052069"},{"Id":408518,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"62756052088"},{"Id":408519,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"62756052169"},{"Id":408520,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"62756052188"},{"Id":408521,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"62756052269"},{"Id":408522,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"62756052288"},{"Id":408523,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"62756052926"},{"Id":408524,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"62756052940"},{"Id":408525,"FormularyType":"OHP","DrugName":"RILUZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74503070000320","GenericName":"RILUZOLE TAB 50 MG","NDC":"62756053886"},{"Id":408526,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 125MG","DosageForm":"TBSO - Tablet Soluble","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007320","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 125 MG","NDC":"62756056883"},{"Id":408527,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 250MG","DosageForm":"TBSO - Tablet Soluble","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007330","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 250 MG","NDC":"62756056983"},{"Id":408528,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 500MG","DosageForm":"TBSO - Tablet Soluble","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007340","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 500 MG","NDC":"62756057083"},{"Id":408529,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"62756058988"},{"Id":408530,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"62756059088"},{"Id":408531,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"62756059188"},{"Id":408532,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"62756070713"},{"Id":408533,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"62756070786"},{"Id":408534,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"62756071013"},{"Id":408535,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"62756071086"},{"Id":408536,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"62756071113"},{"Id":408537,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"62756071186"},{"Id":408538,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"62756071213"},{"Id":408539,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"62756071286"},{"Id":408540,"FormularyType":"OHP","DrugName":"OPCICON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"62756071860"},{"Id":408541,"FormularyType":"OHP","DrugName":"MY CHOICE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"62756072060"},{"Id":408542,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"62756095501"},{"Id":408543,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"62756095601"},{"Id":408544,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"62756095701"},{"Id":408545,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"62756096783"},{"Id":408546,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"62756096788"},{"Id":408547,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.5MCG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000110","GenericName":"CALCITRIOL CAP 0.5 MCG","NDC":"62756096888"},{"Id":408548,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"62756096983"},{"Id":408549,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"62756097083"},{"Id":408550,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"62756098501"},{"Id":408551,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"62756098502"},{"Id":408552,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD PADS 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"62850000001"},{"Id":408553,"FormularyType":"OHP","DrugName":"LEQEMBI IQLK INJ 360/1.8","DosageForm":"SOAJ - Soln Auto-inj","Strength":"360","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6205054530D520","GenericName":"LECANEMAB-IRMB SOLN AUTO-INJ 360 MG/1.8ML","NDC":"62856022001"},{"Id":408554,"FormularyType":"OHP","DrugName":"LENVIMA CAP 4MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B210","GenericName":"LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE)","NDC":"62856070405"},{"Id":408555,"FormularyType":"OHP","DrugName":"LENVIMA CAP 4MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B210","GenericName":"LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE)","NDC":"62856070430"},{"Id":408556,"FormularyType":"OHP","DrugName":"LENVIMA CAP 8 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B215","GenericName":"LENVATINIB CAP THERAPY PACK 2 X 4 MG (8 MG DAILY DOSE)","NDC":"62856070805"},{"Id":408557,"FormularyType":"OHP","DrugName":"LENVIMA CAP 8 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B215","GenericName":"LENVATINIB CAP THERAPY PACK 2 X 4 MG (8 MG DAILY DOSE)","NDC":"62856070830"},{"Id":408558,"FormularyType":"OHP","DrugName":"LENVIMA CAP 10 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B220","GenericName":"LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE)","NDC":"62856071005"},{"Id":408559,"FormularyType":"OHP","DrugName":"LENVIMA CAP 10 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B220","GenericName":"LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE)","NDC":"62856071030"},{"Id":408560,"FormularyType":"OHP","DrugName":"LENVIMA CAP 12MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B223","GenericName":"LENVATINIB CAP THERAPY PACK 3 X 4 MG (12 MG DAILY DOSE)","NDC":"62856071205"},{"Id":408561,"FormularyType":"OHP","DrugName":"LENVIMA CAP 12MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B223","GenericName":"LENVATINIB CAP THERAPY PACK 3 X 4 MG (12 MG DAILY DOSE)","NDC":"62856071230"},{"Id":408562,"FormularyType":"OHP","DrugName":"LENVIMA CAP 14 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B240","GenericName":"LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE)","NDC":"62856071405"},{"Id":408563,"FormularyType":"OHP","DrugName":"LENVIMA CAP 14 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B240","GenericName":"LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE)","NDC":"62856071430"},{"Id":408564,"FormularyType":"OHP","DrugName":"LENVIMA CAP 18 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B244","GenericName":"LENVATINIB CAP THER PACK 10 MG & 2 X 4 MG (18 MG DAILY DOSE)","NDC":"62856071805"},{"Id":408565,"FormularyType":"OHP","DrugName":"LENVIMA CAP 18 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B244","GenericName":"LENVATINIB CAP THER PACK 10 MG & 2 X 4 MG (18 MG DAILY DOSE)","NDC":"62856071830"},{"Id":408566,"FormularyType":"OHP","DrugName":"LENVIMA CAP 20 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B230","GenericName":"LENVATINIB CAP THERAPY PACK 2 X 10 MG (20 MG DAILY DOSE)","NDC":"62856072005"},{"Id":408567,"FormularyType":"OHP","DrugName":"LENVIMA CAP 20 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B230","GenericName":"LENVATINIB CAP THERAPY PACK 2 X 10 MG (20 MG DAILY DOSE)","NDC":"62856072030"},{"Id":408568,"FormularyType":"OHP","DrugName":"LENVIMA CAP 24 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B250","GenericName":"LENVATINIB CAP THER PACK 2 X 10 MG & 4 MG (24 MG DAILY DOSE)","NDC":"62856072405"},{"Id":408569,"FormularyType":"OHP","DrugName":"LENVIMA CAP 24 MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2133505420B250","GenericName":"LENVATINIB CAP THER PACK 2 X 10 MG & 4 MG (24 MG DAILY DOSE)","NDC":"62856072430"},{"Id":408570,"FormularyType":"OHP","DrugName":"ELIGARD INJ 22.5MG","DosageForm":"KIT - Kit","Strength":"22.5","BrandVsGeneric":"M","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010156432","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG","NDC":"62935022305"},{"Id":408571,"FormularyType":"OHP","DrugName":"ELIGARD INJ 22.5MG","DosageForm":"KIT - Kit","Strength":"22.5","BrandVsGeneric":"M","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010156432","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG","NDC":"62935022710"},{"Id":408572,"FormularyType":"OHP","DrugName":"ELIGARD INJ 7.5MG","DosageForm":"KIT - Kit","Strength":"7.5","BrandVsGeneric":"M","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106415","GenericName":"LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG","NDC":"62935075375"},{"Id":408573,"FormularyType":"OHP","DrugName":"ELIGARD INJ 7.5MG","DosageForm":"KIT - Kit","Strength":"7.5","BrandVsGeneric":"M","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106415","GenericName":"LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG","NDC":"62935075680"},{"Id":408574,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"62991131301"},{"Id":408575,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"62991131302"},{"Id":408576,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"62991131303"},{"Id":408577,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"62991131304"},{"Id":408578,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"62991131305"},{"Id":408579,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 1450","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050302900","GenericName":"POLYETHYLENE GLYCOL 1450 POWDER","NDC":"62991131306"},{"Id":408580,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"62991165801"},{"Id":408581,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"62991165803"},{"Id":408582,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"62991165805"},{"Id":408583,"FormularyType":"OHP","DrugName":"COTTONSEED OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"LIQUIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96202020001700","GenericName":"COTTONSEED OIL","NDC":"62991165806"},{"Id":408584,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991200901"},{"Id":408585,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991200902"},{"Id":408586,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991200906"},{"Id":408587,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991200907"},{"Id":408588,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991200908"},{"Id":408589,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991200909"},{"Id":408590,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"62991203401"},{"Id":408591,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"62991203402"},{"Id":408592,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"62991203403"},{"Id":408593,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"62991203404"},{"Id":408594,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"62991305201"},{"Id":408595,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"62991305202"},{"Id":408596,"FormularyType":"OHP","DrugName":"MINERAL OIL LIGHT","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"62991305203"},{"Id":408597,"FormularyType":"OHP","DrugName":"SYRUP SF SYP VEHICLE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"62991308701"},{"Id":408598,"FormularyType":"OHP","DrugName":"SUSPENSION SUS VEHICLE","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"62991308801"},{"Id":408599,"FormularyType":"OHP","DrugName":"SYRUP SYP VEHICLE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"62991308901"},{"Id":408600,"FormularyType":"OHP","DrugName":"SYRUP SYP VEHICLE","DosageForm":"SYRP - Syrup","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001200","GenericName":"*ORAL VEHICLES - SYRUP***","NDC":"62991308902"},{"Id":408601,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991314801"},{"Id":408602,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991314802"},{"Id":408603,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991314803"},{"Id":408604,"FormularyType":"OHP","DrugName":"PEG 3350 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"SEMI SOLID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98600050452900","GenericName":"POLYETHYLENE GLYCOL 3350 POWDER","NDC":"62991314804"},{"Id":408605,"FormularyType":"OHP","DrugName":"VIRACEPT TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104545200320","GenericName":"NELFINAVIR MESYLATE TAB 250 MG","NDC":"63010001030"},{"Id":408606,"FormularyType":"OHP","DrugName":"VIRACEPT TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104545200340","GenericName":"NELFINAVIR MESYLATE TAB 625 MG","NDC":"63010002770"},{"Id":408607,"FormularyType":"OHP","DrugName":"ALUNBRIG TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530510000350","GenericName":"BRIGATINIB TAB 90 MG","NDC":"63020009007"},{"Id":408608,"FormularyType":"OHP","DrugName":"ALUNBRIG TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530510000350","GenericName":"BRIGATINIB TAB 90 MG","NDC":"63020009030"},{"Id":408609,"FormularyType":"OHP","DrugName":"ALUNBRIG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530510000330","GenericName":"BRIGATINIB TAB 30 MG","NDC":"63020011330"},{"Id":408610,"FormularyType":"OHP","DrugName":"ALUNBRIG TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21530510000365","GenericName":"BRIGATINIB TAB 180 MG","NDC":"63020018030"},{"Id":408611,"FormularyType":"OHP","DrugName":"ALUNBRIG PAK","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153051000B720","GenericName":"BRIGATINIB TAB INITIATION THERAPY PACK 90 MG & 180 MG","NDC":"63020019830"},{"Id":408612,"FormularyType":"OHP","DrugName":"FRUZAQLA CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21335035000120","GenericName":"FRUQUINTINIB CAP 1 MG","NDC":"63020021021"},{"Id":408613,"FormularyType":"OHP","DrugName":"FRUZAQLA CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21335035000140","GenericName":"FRUQUINTINIB CAP 5 MG","NDC":"63020022521"},{"Id":408614,"FormularyType":"OHP","DrugName":"NINLARO CAP 2.3MG","DosageForm":"CAPS - Capsule","Strength":"2.3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100120","GenericName":"IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT)","NDC":"63020023001"},{"Id":408615,"FormularyType":"OHP","DrugName":"NINLARO CAP 2.3MG","DosageForm":"CAPS - Capsule","Strength":"2.3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100120","GenericName":"IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT)","NDC":"63020023002"},{"Id":408616,"FormularyType":"OHP","DrugName":"NINLARO CAP 2.3MG","DosageForm":"CAPS - Capsule","Strength":"2.3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100120","GenericName":"IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT)","NDC":"63020023003"},{"Id":408617,"FormularyType":"OHP","DrugName":"NINLARO CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100130","GenericName":"IXAZOMIB CITRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"63020039001"},{"Id":408618,"FormularyType":"OHP","DrugName":"NINLARO CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100130","GenericName":"IXAZOMIB CITRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"63020039002"},{"Id":408619,"FormularyType":"OHP","DrugName":"NINLARO CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100130","GenericName":"IXAZOMIB CITRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"63020039003"},{"Id":408620,"FormularyType":"OHP","DrugName":"NINLARO CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100140","GenericName":"IXAZOMIB CITRATE CAP 4 MG (BASE EQUIVALENT)","NDC":"63020040001"},{"Id":408621,"FormularyType":"OHP","DrugName":"NINLARO CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100140","GenericName":"IXAZOMIB CITRATE CAP 4 MG (BASE EQUIVALENT)","NDC":"63020040002"},{"Id":408622,"FormularyType":"OHP","DrugName":"NINLARO CAP 4MG","DosageForm":"CAPS - Capsule","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21536045100140","GenericName":"IXAZOMIB CITRATE CAP 4 MG (BASE EQUIVALENT)","NDC":"63020040003"},{"Id":408623,"FormularyType":"OHP","DrugName":"ICLUSIG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531875100330","GenericName":"PONATINIB HCL TAB 30 MG (BASE EQUIV)","NDC":"63020053330"},{"Id":408624,"FormularyType":"OHP","DrugName":"ICLUSIG TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531875100340","GenericName":"PONATINIB HCL TAB 45 MG (BASE EQUIV)","NDC":"63020053430"},{"Id":408625,"FormularyType":"OHP","DrugName":"ICLUSIG TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531875100320","GenericName":"PONATINIB HCL TAB 15 MG (BASE EQUIV)","NDC":"63020053530"},{"Id":408626,"FormularyType":"OHP","DrugName":"ICLUSIG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531875100315","GenericName":"PONATINIB HCL TAB 10 MG (BASE EQUIV)","NDC":"63020053630"},{"Id":408627,"FormularyType":"OHP","DrugName":"INATAL GT TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512065000375","GenericName":"*PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***","NDC":"63044015910"},{"Id":408628,"FormularyType":"OHP","DrugName":"IFEREX 150 CAP","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"63044020301"},{"Id":408629,"FormularyType":"OHP","DrugName":"IFEREX 150 CAP","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"63044020361"},{"Id":408630,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"63044040101"},{"Id":408631,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"63044040201"},{"Id":408632,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"63044040420"},{"Id":408633,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"63044048409"},{"Id":408634,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"63044401101"},{"Id":408635,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"63304001760"},{"Id":408636,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"63304001860"},{"Id":408637,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"63304004127"},{"Id":408638,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"63304004227"},{"Id":408639,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"63304004327"},{"Id":408640,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"63304004422"},{"Id":408641,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"63304004522"},{"Id":408642,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"63304004622"},{"Id":408643,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"63304007601"},{"Id":408644,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"63304007605"},{"Id":408645,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"63304007610"},{"Id":408646,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 8MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000205","GenericName":"POTASSIUM CHLORIDE CAP ER 8 MEQ","NDC":"63304007801"},{"Id":408647,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 500MG ER","DosageForm":"CPCR - Capsule ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000220","GenericName":"MESALAMINE CAP ER 500 MG","NDC":"63304008913"},{"Id":408648,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"63304009001"},{"Id":408649,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"63304009005"},{"Id":408650,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"63304009127"},{"Id":408651,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"63304009227"},{"Id":408652,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"63304009327"},{"Id":408653,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"63304009427"},{"Id":408654,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"63304009530"},{"Id":408655,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"63304009630"},{"Id":408656,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"63304009719"},{"Id":408657,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"63304009819"},{"Id":408658,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"63304009919"},{"Id":408659,"FormularyType":"OHP","DrugName":"PAZOPANIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533042100320","GenericName":"PAZOPANIB HCL TAB 200 MG (BASE EQUIV)","NDC":"63304011613"},{"Id":408660,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"63304012877"},{"Id":408661,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"63304013204"},{"Id":408662,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"63304013530"},{"Id":408663,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"63304014801"},{"Id":408664,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"63304014901"},{"Id":408665,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"63304014950"},{"Id":408666,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100105","GenericName":"BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT)","NDC":"63304015801"},{"Id":408667,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100105","GenericName":"BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT)","NDC":"63304015830"},{"Id":408668,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"63304017513"},{"Id":408669,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"63304023901"},{"Id":408670,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"63304023930"},{"Id":408671,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.5MCG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000110","GenericName":"CALCITRIOL CAP 0.5 MCG","NDC":"63304024001"},{"Id":408672,"FormularyType":"OHP","DrugName":"CALCITRIOL SOL 1MCG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030002050","GenericName":"CALCITRIOL ORAL SOLN 1 MCG/ML","NDC":"63304024159"},{"Id":408673,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"63304031330"},{"Id":408674,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"63304031390"},{"Id":408675,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"63304033701"},{"Id":408676,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"63304033801"},{"Id":408677,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"63304033805"},{"Id":408678,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"63304033901"},{"Id":408679,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"63304033905"},{"Id":408680,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"63304034001"},{"Id":408681,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"63304034005"},{"Id":408682,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"63304043501"},{"Id":408683,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"63304043601"},{"Id":408684,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"63304043701"},{"Id":408685,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 43MG","DosageForm":"CAPS - Capsule","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100104","GenericName":"FENOFIBRATE MICRONIZED CAP 43 MG","NDC":"63304044330"},{"Id":408686,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"63304044905"},{"Id":408687,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"63304044990"},{"Id":408688,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"63304045001"},{"Id":408689,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG ER","DosageForm":"TBCR - Tablet ER","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100432","GenericName":"MORPHINE SULFATE TAB ER 30 MG","NDC":"63304045101"},{"Id":408690,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 100MG ER","DosageForm":"TBCR - Tablet ER","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100460","GenericName":"MORPHINE SULFATE TAB ER 100 MG","NDC":"63304045201"},{"Id":408691,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 200MG ER","DosageForm":"TBCR - Tablet ER","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100480","GenericName":"MORPHINE SULFATE TAB ER 200 MG","NDC":"63304045301"},{"Id":408692,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"63304045830"},{"Id":408693,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"63304045930"},{"Id":408694,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"63304050401"},{"Id":408695,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"63304050501"},{"Id":408696,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"63304053101"},{"Id":408697,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"63304053201"},{"Id":408698,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"63304053401"},{"Id":408699,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"63304053501"},{"Id":408700,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"63304053705"},{"Id":408701,"FormularyType":"OHP","DrugName":"FOSAMPRENAVI TAB 700MG","DosageForm":"TABS - Tablet","Strength":"700","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104525100330","GenericName":"FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV)","NDC":"63304058360"},{"Id":408702,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"63304061650"},{"Id":408703,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"63304065201"},{"Id":408704,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"63304065205"},{"Id":408705,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"63304069201"},{"Id":408706,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"63304069205"},{"Id":408707,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"63304069301"},{"Id":408708,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"63304069316"},{"Id":408709,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"63304069401"},{"Id":408710,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"63304069605"},{"Id":408711,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"63304069650"},{"Id":408712,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"63304071805"},{"Id":408713,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"63304071890"},{"Id":408714,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"63304071905"},{"Id":408715,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"63304071990"},{"Id":408716,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"63304072005"},{"Id":408717,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"63304072090"},{"Id":408718,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"63304072105"},{"Id":408719,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"63304072190"},{"Id":408720,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"63304072290"},{"Id":408721,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"63304073410"},{"Id":408722,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"63304073510"},{"Id":408723,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 60MG ER","DosageForm":"TBCR - Tablet ER","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100445","GenericName":"MORPHINE SULFATE TAB ER 60 MG","NDC":"63304075801"},{"Id":408724,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"63304078990"},{"Id":408725,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"63304079090"},{"Id":408726,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"63304082705"},{"Id":408727,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"63304082790"},{"Id":408728,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"63304082805"},{"Id":408729,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"63304082890"},{"Id":408730,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"63304082905"},{"Id":408731,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"63304082990"},{"Id":408732,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"63304083005"},{"Id":408733,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"63304083090"},{"Id":408734,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"63304090105"},{"Id":408735,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"63304090430"},{"Id":408736,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"63304090490"},{"Id":408737,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"63304090530"},{"Id":408738,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"63304090590"},{"Id":408739,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"63304096001"},{"Id":408740,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"63304096003"},{"Id":408741,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"63304096101"},{"Id":408742,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"63304096201"},{"Id":408743,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"63304096230"},{"Id":408744,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"63304098701"},{"Id":408745,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"63304098705"},{"Id":408746,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"63304098710"},{"Id":408747,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001001"},{"Id":408748,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001002"},{"Id":408749,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001003"},{"Id":408750,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001020"},{"Id":408751,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001041"},{"Id":408752,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001042"},{"Id":408753,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001094"},{"Id":408754,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001095"},{"Id":408755,"FormularyType":"OHP","DrugName":"GENTAMICIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000020102045","GenericName":"GENTAMICIN SULFATE INJ 40 MG/ML","NDC":"63323001096"},{"Id":408756,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"63323004400"},{"Id":408757,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"63323004401"},{"Id":408758,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"63323004441"},{"Id":408759,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"63323004444"},{"Id":408760,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"63323008303"},{"Id":408761,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 4.2%","DosageForm":"SOLN - Solution","Strength":"4.2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002010","GenericName":"SODIUM BICARBONATE IV SOLN 4.2%","NDC":"63323008305"},{"Id":408762,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323008861"},{"Id":408763,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"63323008925"},{"Id":408764,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"63323008950"},{"Id":408765,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 2.5/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002050","GenericName":"SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","NDC":"63323009002"},{"Id":408766,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 2.5/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002050","GenericName":"SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","NDC":"63323009004"},{"Id":408767,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 2.5/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002050","GenericName":"SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","NDC":"63323009020"},{"Id":408768,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 2.5/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002050","GenericName":"SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","NDC":"63323009040"},{"Id":408769,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 4MEQ/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323009301"},{"Id":408770,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 4MEQ/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323009330"},{"Id":408771,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323009502"},{"Id":408772,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323009561"},{"Id":408773,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323009903"},{"Id":408774,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 23.4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002045","GenericName":"SODIUM CHLORIDE IV SOLN 4 MEQ/ML (23.4%)","NDC":"63323009963"},{"Id":408775,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 250/10ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102069","GenericName":"METHOTREXATE SODIUM INJ PF 250 MG/10ML (25 MG/ML)","NDC":"63323012110"},{"Id":408776,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102150","GenericName":"METHOTREXATE SODIUM FOR INJ 1 GM","NDC":"63323012250"},{"Id":408777,"FormularyType":"OHP","DrugName":"METHOTREXATE INJ 25MG/ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050102068","GenericName":"METHOTREXATE SODIUM INJ 250 MG/10ML (25 MG/ML)","NDC":"63323012310"},{"Id":408778,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323017826"},{"Id":408779,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323017876"},{"Id":408780,"FormularyType":"OHP","DrugName":"FOLIC ACID INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010002005","GenericName":"FOLIC ACID INJ 5 MG/ML","NDC":"63323018410"},{"Id":408781,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018504"},{"Id":408782,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018505"},{"Id":408783,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018507"},{"Id":408784,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018508"},{"Id":408785,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018509"},{"Id":408786,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018510"},{"Id":408787,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018520"},{"Id":408788,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"63323018550"},{"Id":408789,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"63323018601"},{"Id":408790,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"63323018602"},{"Id":408791,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"63323018603"},{"Id":408792,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"63323018604"},{"Id":408793,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"63323018610"},{"Id":408794,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"63323018620"},{"Id":408795,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"63323020301"},{"Id":408796,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"63323020320"},{"Id":408797,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"63323020326"},{"Id":408798,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"63323020341"},{"Id":408799,"FormularyType":"OHP","DrugName":"LIDOCAINE INJ 20MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200020102035","GenericName":"LIDOCAINE HCL (CARDIAC) IV PF SOLN 100 MG/5ML (2%)","NDC":"63323020801"},{"Id":408800,"FormularyType":"OHP","DrugName":"LIDOCAINE INJ 20MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200020102035","GenericName":"LIDOCAINE HCL (CARDIAC) IV PF SOLN 100 MG/5ML (2%)","NDC":"63323020805"},{"Id":408801,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"63323022116"},{"Id":408802,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"63323022141"},{"Id":408803,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102110","GenericName":"CEFAZOLIN SODIUM FOR INJ 500 MG","NDC":"63323023610"},{"Id":408804,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"63323023710"},{"Id":408805,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"63323023801"},{"Id":408806,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"63323023861"},{"Id":408807,"FormularyType":"OHP","DrugName":"MURI-LUBE OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"63323025402"},{"Id":408808,"FormularyType":"OHP","DrugName":"MURI-LUBE OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010051750","GenericName":"MINERAL OIL LIGHT (BULK)","NDC":"63323025410"},{"Id":408809,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"63323025501"},{"Id":408810,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"63323025503"},{"Id":408811,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"63323026203"},{"Id":408812,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"63323026206"},{"Id":408813,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"63323026209"},{"Id":408814,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"63323026211"},{"Id":408815,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"63323026226"},{"Id":408816,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"63323026236"},{"Id":408817,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/0.5","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"63323027301"},{"Id":408818,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028001"},{"Id":408819,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028002"},{"Id":408820,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028003"},{"Id":408821,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028004"},{"Id":408822,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028005"},{"Id":408823,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028010"},{"Id":408824,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028016"},{"Id":408825,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028026"},{"Id":408826,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028036"},{"Id":408827,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028043"},{"Id":408828,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"63323028045"},{"Id":408829,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"63323028401"},{"Id":408830,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"63323028420"},{"Id":408831,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"63323028421"},{"Id":408832,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"63323028426"},{"Id":408833,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"63323028442"},{"Id":408834,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"63323029561"},{"Id":408835,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"63323029566"},{"Id":408836,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"63323030474"},{"Id":408837,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"63323030478"},{"Id":408838,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"63323030601"},{"Id":408839,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"63323030602"},{"Id":408840,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102038","GenericName":"TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","NDC":"63323030605"},{"Id":408841,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 40MG/ML","DosageForm":"SOLN - Solution","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102038","GenericName":"TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","NDC":"63323030630"},{"Id":408842,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"63323031461"},{"Id":408843,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"63323031466"},{"Id":408844,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"63323031468"},{"Id":408845,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102010","GenericName":"GRANISETRON HCL INJ 1 MG/ML","NDC":"63323031801"},{"Id":408846,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"63323032201"},{"Id":408847,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"63323032221"},{"Id":408848,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"63323032225"},{"Id":408849,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"63323032241"},{"Id":408850,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"63323032293"},{"Id":408851,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402120","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","NDC":"63323032294"},{"Id":408852,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"63323032620"},{"Id":408853,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102110","GenericName":"CEFEPIME HCL FOR INJ 1 GM","NDC":"63323032621"},{"Id":408854,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102105","GenericName":"NAFCILLIN SODIUM FOR INJ 1 GM","NDC":"63323032710"},{"Id":408855,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102105","GenericName":"NAFCILLIN SODIUM FOR INJ 1 GM","NDC":"63323032721"},{"Id":408856,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"63323032820"},{"Id":408857,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"63323032821"},{"Id":408858,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"63323032822"},{"Id":408859,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"63323033060"},{"Id":408860,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"63323034020"},{"Id":408861,"FormularyType":"OHP","DrugName":"CEFEPIME INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 4TH GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02400040102122","GenericName":"CEFEPIME HCL FOR IV SOLN 2 GM","NDC":"63323034021"},{"Id":408862,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"63323034101"},{"Id":408863,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"63323034125"},{"Id":408864,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"63323034129"},{"Id":408865,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102105","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 1 GM","NDC":"63323034141"},{"Id":408866,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"63323034201"},{"Id":408867,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"63323034225"},{"Id":408868,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"63323034229"},{"Id":408869,"FormularyType":"OHP","DrugName":"CEFOXITIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200060102110","GenericName":"CEFOXITIN SODIUM FOR IV SOLN 2 GM","NDC":"63323034241"},{"Id":408870,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"63323034610"},{"Id":408871,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402110","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","NDC":"63323034901"},{"Id":408872,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402110","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","NDC":"63323034921"},{"Id":408873,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402110","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","NDC":"63323034925"},{"Id":408874,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402110","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","NDC":"63323034941"},{"Id":408875,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402110","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","NDC":"63323034993"},{"Id":408876,"FormularyType":"OHP","DrugName":"IMIPENEM/CIL INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16159902402110","GenericName":"IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","NDC":"63323034994"},{"Id":408877,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 250/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112024","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","NDC":"63323035550"},{"Id":408878,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112032","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","NDC":"63323035560"},{"Id":408879,"FormularyType":"OHP","DrugName":"LEVOFLOX/D5W INJ 500/100M","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034112028","GenericName":"LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","NDC":"63323035565"},{"Id":408880,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"63323037600"},{"Id":408881,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"63323037601"},{"Id":408882,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"63323037604"},{"Id":408883,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"63323037641"},{"Id":408884,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102030","GenericName":"OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML)","NDC":"63323037905"},{"Id":408885,"FormularyType":"OHP","DrugName":"CEFOTETAN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200057102110","GenericName":"CEFOTETAN DISODIUM FOR INJ 1 GM","NDC":"63323038501"},{"Id":408886,"FormularyType":"OHP","DrugName":"CEFOTETAN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200057102110","GenericName":"CEFOTETAN DISODIUM FOR INJ 1 GM","NDC":"63323038510"},{"Id":408887,"FormularyType":"OHP","DrugName":"CEFOTETAN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200057102120","GenericName":"CEFOTETAN DISODIUM FOR INJ 2 GM","NDC":"63323038601"},{"Id":408888,"FormularyType":"OHP","DrugName":"CEFOTETAN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200057102120","GenericName":"CEFOTETAN DISODIUM FOR INJ 2 GM","NDC":"63323038620"},{"Id":408889,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"63323039306"},{"Id":408890,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"63323039801"},{"Id":408891,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"63323039810"},{"Id":408892,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"63323039812"},{"Id":408893,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"63323039814"},{"Id":408894,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"63323039841"},{"Id":408895,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"63323040101"},{"Id":408896,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"63323040120"},{"Id":408897,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"63323040121"},{"Id":408898,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"63323040124"},{"Id":408899,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"63323040126"},{"Id":408900,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002120","GenericName":"AZTREONAM FOR INJ 1 GM","NDC":"63323040141"},{"Id":408901,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"63323040201"},{"Id":408902,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"63323040203"},{"Id":408903,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"63323040220"},{"Id":408904,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"63323040224"},{"Id":408905,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"63323040230"},{"Id":408906,"FormularyType":"OHP","DrugName":"AZTREONAM INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"MONOBACTAMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16140010002130","GenericName":"AZTREONAM FOR INJ 2 GM","NDC":"63323040241"},{"Id":408907,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"63323040301"},{"Id":408908,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"63323040302"},{"Id":408909,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"63323040304"},{"Id":408910,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"63323040310"},{"Id":408911,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"63323040601"},{"Id":408912,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"63323040603"},{"Id":408913,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"63323040703"},{"Id":408914,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"63323040704"},{"Id":408915,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"63323041118"},{"Id":408916,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"63323041125"},{"Id":408917,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102010","GenericName":"MIDAZOLAM HCL INJ 10 MG/2ML (BASE EQUIVALENT)","NDC":"63323041202"},{"Id":408918,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102010","GenericName":"MIDAZOLAM HCL INJ 10 MG/2ML (BASE EQUIVALENT)","NDC":"63323041203"},{"Id":408919,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"63323041210"},{"Id":408920,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"63323041213"},{"Id":408921,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102005","GenericName":"MIDAZOLAM HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"63323041218"},{"Id":408922,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102005","GenericName":"MIDAZOLAM HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"63323041225"},{"Id":408923,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102052","GenericName":"MORPHINE SULFATE INJ PF 10 MG/ML","NDC":"63323045100"},{"Id":408924,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102052","GenericName":"MORPHINE SULFATE INJ PF 10 MG/ML","NDC":"63323045101"},{"Id":408925,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102055","GenericName":"MORPHINE SULFATE INJ PF 2 MG/ML","NDC":"63323045200"},{"Id":408926,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102055","GenericName":"MORPHINE SULFATE INJ PF 2 MG/ML","NDC":"63323045201"},{"Id":408927,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102011","GenericName":"MORPHINE SULFATE INJ PF 4 MG/ML","NDC":"63323045400"},{"Id":408928,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102011","GenericName":"MORPHINE SULFATE INJ PF 4 MG/ML","NDC":"63323045401"},{"Id":408929,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"63323050701"},{"Id":408930,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"63323050720"},{"Id":408931,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"63323050721"},{"Id":408932,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"63323050725"},{"Id":408933,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"63323050801"},{"Id":408934,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"63323050821"},{"Id":408935,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"63323050825"},{"Id":408936,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"63323050830"},{"Id":408937,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"63323050831"},{"Id":408938,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"63323050845"},{"Id":408939,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 3%","DosageForm":"SOLN - Solution","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002030","GenericName":"SODIUM CHLORIDE IV SOLN 3%","NDC":"63323053021"},{"Id":408940,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 3%","DosageForm":"SOLN - Solution","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002030","GenericName":"SODIUM CHLORIDE IV SOLN 3%","NDC":"63323053075"},{"Id":408941,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323053101"},{"Id":408942,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323053108"},{"Id":408943,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323053190"},{"Id":408944,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323053198"},{"Id":408945,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323053301"},{"Id":408946,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323053313"},{"Id":408947,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323053383"},{"Id":408948,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323053393"},{"Id":408949,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323053501"},{"Id":408950,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323053508"},{"Id":408951,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323053587"},{"Id":408952,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323053598"},{"Id":408953,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"63323053701"},{"Id":408954,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"63323053784"},{"Id":408955,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 300/3ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101020102050","GenericName":"ENOXAPARIN SODIUM INJ 300 MG/3ML","NDC":"63323053903"},{"Id":408956,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054003"},{"Id":408957,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054005"},{"Id":408958,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054007"},{"Id":408959,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054013"},{"Id":408960,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054015"},{"Id":408961,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054033"},{"Id":408962,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054036"},{"Id":408963,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"63323054067"},{"Id":408964,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"63323054204"},{"Id":408965,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"63323054209"},{"Id":408966,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"63323054213"},{"Id":408967,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"63323054214"},{"Id":408968,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"63323054303"},{"Id":408969,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"63323054313"},{"Id":408970,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323055921"},{"Id":408971,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323055963"},{"Id":408972,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323055965"},{"Id":408973,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"63323055993"},{"Id":408974,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323056421"},{"Id":408975,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323056463"},{"Id":408976,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323056465"},{"Id":408977,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"63323056497"},{"Id":408978,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"63323056621"},{"Id":408979,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"63323056663"},{"Id":408980,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"63323056665"},{"Id":408981,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"63323056698"},{"Id":408982,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"63323057401"},{"Id":408983,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"63323057486"},{"Id":408984,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"63323057493"},{"Id":408985,"FormularyType":"OHP","DrugName":"GLUCAGON EMR SOL 1MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010202105","GenericName":"GLUCAGON HCL FOR INJ 1 MG","NDC":"63323058282"},{"Id":408986,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323058421"},{"Id":408987,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323058463"},{"Id":408988,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323058465"},{"Id":408989,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"63323058499"},{"Id":408990,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"63323058621"},{"Id":408991,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"63323058663"},{"Id":408992,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"63323058665"},{"Id":408993,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"63323058696"},{"Id":408994,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"63323058921"},{"Id":408995,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"63323058994"},{"Id":408996,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"63323060501"},{"Id":408997,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"63323060584"},{"Id":408998,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"63323060701"},{"Id":408999,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"63323060788"},{"Id":409000,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"63323060901"},{"Id":409001,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"63323060990"},{"Id":409002,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"63323061601"},{"Id":409003,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 450MG/9M","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"63323061602"},{"Id":409004,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"63323061603"},{"Id":409005,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 450MG/9M","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"63323061609"},{"Id":409006,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062600"},{"Id":409007,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062601"},{"Id":409008,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062602"},{"Id":409009,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062603"},{"Id":409010,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062604"},{"Id":409011,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062605"},{"Id":409012,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062610"},{"Id":409013,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062625"},{"Id":409014,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062650"},{"Id":409015,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"63323062655"},{"Id":409016,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 200MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"200","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102107","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 200 MCG","NDC":"63323064710"},{"Id":409017,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 500MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102112","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 500 MCG","NDC":"63323064810"},{"Id":409018,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"63323064907"},{"Id":409019,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"63323064916"},{"Id":409020,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"O","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"63323064994"},{"Id":409021,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"63323065100"},{"Id":409022,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"63323065101"},{"Id":409023,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"63323065102"},{"Id":409024,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"63323065104"},{"Id":409025,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"63323065121"},{"Id":409026,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"63323065123"},{"Id":409027,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"63323065189"},{"Id":409028,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"63323065190"},{"Id":409029,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"63323065521"},{"Id":409030,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"63323065599"},{"Id":409031,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"63323066400"},{"Id":409032,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"63323066401"},{"Id":409033,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"63323066416"},{"Id":409034,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"63323066441"},{"Id":409035,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"63323071303"},{"Id":409036,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"63323071313"},{"Id":409037,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102131","GenericName":"OXACILLIN SODIUM FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"63323081100"},{"Id":409038,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102120","GenericName":"OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT)","NDC":"63323081201"},{"Id":409039,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102120","GenericName":"OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT)","NDC":"63323081220"},{"Id":409040,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102115","GenericName":"OXACILLIN SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"63323081301"},{"Id":409041,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102115","GenericName":"OXACILLIN SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"63323081320"},{"Id":409042,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"63323081502"},{"Id":409043,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"63323081504"},{"Id":409044,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"63323081521"},{"Id":409045,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"63323081522"},{"Id":409046,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"63323082301"},{"Id":409047,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"63323082320"},{"Id":409048,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"63323082424"},{"Id":409049,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"63323082425"},{"Id":409050,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"63323082426"},{"Id":409051,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"63323082474"},{"Id":409052,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"63323082475"},{"Id":409053,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002020","GenericName":"DEXTROSE INJ 10%","NDC":"63323082476"},{"Id":409054,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN INJ 400/250","DosageForm":"SOLN - Solution","Strength":"400","BrandVsGeneric":"N","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037102020","GenericName":"MOXIFLOXACIN HCL IV SOLUTION 400 MG/250ML (BASE EQUIV)","NDC":"63323085004"},{"Id":409055,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN INJ 400/250","DosageForm":"SOLN - Solution","Strength":"400","BrandVsGeneric":"N","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037102020","GenericName":"MOXIFLOXACIN HCL IV SOLUTION 400 MG/250ML (BASE EQUIV)","NDC":"63323085074"},{"Id":409056,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"63323085103"},{"Id":409057,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"63323085107"},{"Id":409058,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"63323085110"},{"Id":409059,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"63323085115"},{"Id":409060,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"O","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102027","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 10 MG/ML","NDC":"63323085150"},{"Id":409061,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102007","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 1 MG/ML","NDC":"63323085203"},{"Id":409062,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102007","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 1 MG/ML","NDC":"63323085225"},{"Id":409063,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102012","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 2 MG/ML","NDC":"63323085303"},{"Id":409064,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102012","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 2 MG/ML","NDC":"63323085325"},{"Id":409065,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102022","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 4 MG/ML","NDC":"63323085403"},{"Id":409066,"FormularyType":"OHP","DrugName":"HYDROMORPHON INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100035102022","GenericName":"HYDROMORPHONE HCL PRESERVATIVE FREE (PF) INJ 4 MG/ML","NDC":"63323085410"},{"Id":409067,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"63323086901"},{"Id":409068,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"63323086904"},{"Id":409069,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"63323086905"},{"Id":409070,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"63323086910"},{"Id":409071,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"63323086974"},{"Id":409072,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202030","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%","NDC":"63323086975"},{"Id":409073,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"63323087001"},{"Id":409074,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"63323087004"},{"Id":409075,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"63323087010"},{"Id":409076,"FormularyType":"OHP","DrugName":"D5W/NACL INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79993002202035","GenericName":"DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%","NDC":"63323087074"},{"Id":409077,"FormularyType":"OHP","DrugName":"FLOW-EZE MIS VENTED","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020006300","GenericName":"HYPODERMIC NEEDLES (DISPOSABLE)","NDC":"63323090490"},{"Id":409078,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"63323091503"},{"Id":409079,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"63323091513"},{"Id":409080,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096501"},{"Id":409081,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096502"},{"Id":409082,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096503"},{"Id":409083,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096505"},{"Id":409084,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096510"},{"Id":409085,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096520"},{"Id":409086,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096701"},{"Id":409087,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002005","GenericName":"POTASSIUM CHLORIDE INJ 2 MEQ/ML","NDC":"63323096730"},{"Id":409088,"FormularyType":"OHP","DrugName":"BENZTROPINE INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010102005","GenericName":"BENZTROPINE MESYLATE INJ 1 MG/ML","NDC":"63323097002"},{"Id":409089,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"63323098141"},{"Id":409090,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"63323098153"},{"Id":409091,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"63323098341"},{"Id":409092,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"63323098353"},{"Id":409093,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"63517060001"},{"Id":409094,"FormularyType":"OHP","DrugName":"XELJANZ TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065100320","GenericName":"TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT)","NDC":"63539001202"},{"Id":409095,"FormularyType":"OHP","DrugName":"XELJANZ TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065100330","GenericName":"TOFACITINIB CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"63539001602"},{"Id":409096,"FormularyType":"OHP","DrugName":"XELJANZ XR TAB 11MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"11","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065107530","GenericName":"TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT)","NDC":"63539050130"},{"Id":409097,"FormularyType":"OHP","DrugName":"XELJANZ XR TAB 22MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"22","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTIRHEUMATIC - ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66603065107550","GenericName":"TOFACITINIB CITRATE TAB ER 24HR 22 MG (BASE EQUIVALENT)","NDC":"63539050230"},{"Id":409098,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"63561012001"},{"Id":409099,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"63561012002"},{"Id":409100,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"63561012005"},{"Id":409101,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"63561012101"},{"Id":409102,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"63561012102"},{"Id":409103,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"63561012105"},{"Id":409104,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"63561012201"},{"Id":409105,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"63561012202"},{"Id":409106,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"63561012205"},{"Id":409107,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"63561016401"},{"Id":409108,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"63561016402"},{"Id":409109,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"63561016409"},{"Id":409110,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"63561016501"},{"Id":409111,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"63561016502"},{"Id":409112,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"63561016509"},{"Id":409113,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"63561016601"},{"Id":409114,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"63561016605"},{"Id":409115,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"63561016609"},{"Id":409116,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"63561017301"},{"Id":409117,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"63561017305"},{"Id":409118,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"63561017401"},{"Id":409119,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"63561017405"},{"Id":409120,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"63629107101"},{"Id":409121,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"63629107102"},{"Id":409122,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"63629107103"},{"Id":409123,"FormularyType":"OHP","DrugName":"CAYA DPR","DosageForm":"DPRH - Diaphragm","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97402010005400","GenericName":"*DIAPHRAGM ARC-SPRING***","NDC":"63704002001"},{"Id":409124,"FormularyType":"OHP","DrugName":"NIX CREM RIN LIQ 1%","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"63736012002"},{"Id":409125,"FormularyType":"OHP","DrugName":"NIX CREM RIN LIQ 1%","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"63736012003"},{"Id":409126,"FormularyType":"OHP","DrugName":"DERMAREST LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"63736033942"},{"Id":409127,"FormularyType":"OHP","DrugName":"MONIST CARE CRE CARE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"N","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFLAMMATORY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55151040003720","GenericName":"HYDROCORTISONE PERIVAGINAL CREAM 1%","NDC":"63736044700"},{"Id":409128,"FormularyType":"OHP","DrugName":"DERMAREST GEL 3%","DosageForm":"GEL - Gel","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004080","GenericName":"SALICYLIC ACID GEL 3%","NDC":"63736073010"},{"Id":409129,"FormularyType":"OHP","DrugName":"DERMAREST SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"63736073020"},{"Id":409130,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"63739005257"},{"Id":409131,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"63739005269"},{"Id":409132,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"63739005802"},{"Id":409133,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"63739015110"},{"Id":409134,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"63739015210"},{"Id":409135,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"63739015832"},{"Id":409136,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"63739015878"},{"Id":409137,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"63739019601"},{"Id":409138,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"63739019610"},{"Id":409139,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"63739029102"},{"Id":409140,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"63739029710"},{"Id":409141,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"63739029810"},{"Id":409142,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"63739036810"},{"Id":409143,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"63739036910"},{"Id":409144,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG CINN","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"63739037010"},{"Id":409145,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"63739037163"},{"Id":409146,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"63739072401"},{"Id":409147,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"63739072450"},{"Id":409148,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"63739090210"},{"Id":409149,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"63739090310"},{"Id":409150,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"63739090410"},{"Id":409151,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"63739097210"},{"Id":409152,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"63739097310"},{"Id":409153,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"63739099764"},{"Id":409154,"FormularyType":"OHP","DrugName":"HAEGARDA INJ 2000UNIT","DosageForm":"SOLR - Solution Reconstituted","Strength":"2000","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85802022002130","GenericName":"C1 ESTERASE INHIBITOR (HUMAN) FOR SUBCUTANEOUS INJ 2000 UNIT","NDC":"63833082802"},{"Id":409155,"FormularyType":"OHP","DrugName":"HAEGARDA INJ 3000UNIT","DosageForm":"SOLR - Solution Reconstituted","Strength":"3000","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"COMPLEMENT INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85802022002140","GenericName":"C1 ESTERASE INHIBITOR (HUMAN) FOR SUBCUTANEOUS INJ 3000 UNIT","NDC":"63833082902"},{"Id":409156,"FormularyType":"OHP","DrugName":"ANDEMBRY INJ 200/1.2","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLASMA FACTOR XIIA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8583203001D520","GenericName":"GARADACIMAB-GXII SOLN AUTO-INJECTOR 200 MG/1.2ML","NDC":"63833092501"},{"Id":409157,"FormularyType":"OHP","DrugName":"ANDEMBRY INJ 200/1.2","DosageForm":"SOAJ - Soln Auto-inj","Strength":"200","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLASMA FACTOR XIIA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8583203001D520","GenericName":"GARADACIMAB-GXII SOLN AUTO-INJECTOR 200 MG/1.2ML","NDC":"63833092520"},{"Id":409158,"FormularyType":"OHP","DrugName":"QC PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"63868000101"},{"Id":409159,"FormularyType":"OHP","DrugName":"QC MENSTRUAL TAB COMPLETE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003050320","GenericName":"ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB 500-60-15 MG","NDC":"63868003224"},{"Id":409160,"FormularyType":"OHP","DrugName":"MOTION SICK TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"63868003412"},{"Id":409161,"FormularyType":"OHP","DrugName":"MOTION SICK TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"63868003424"},{"Id":409162,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"63868004715"},{"Id":409163,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"63868004872"},{"Id":409164,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"63868004972"},{"Id":409165,"FormularyType":"OHP","DrugName":"CALC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"63868005315"},{"Id":409166,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"63868008210"},{"Id":409167,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008310"},{"Id":409168,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008360"},{"Id":409169,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008405"},{"Id":409170,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008410"},{"Id":409171,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008424"},{"Id":409172,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008450"},{"Id":409173,"FormularyType":"OHP","DrugName":"COMP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"63868008701"},{"Id":409174,"FormularyType":"OHP","DrugName":"COMP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"63868008724"},{"Id":409175,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008801"},{"Id":409176,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008803"},{"Id":409177,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008815"},{"Id":409178,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008824"},{"Id":409179,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868008850"},{"Id":409180,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868008901"},{"Id":409181,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868008905"},{"Id":409182,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868008910"},{"Id":409183,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868008950"},{"Id":409184,"FormularyType":"OHP","DrugName":"QC APAP 8 HR TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868009150"},{"Id":409185,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"63868011001"},{"Id":409186,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"63868011025"},{"Id":409187,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"63868012722"},{"Id":409188,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"63868012804"},{"Id":409189,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"63868013066"},{"Id":409190,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63868013214"},{"Id":409191,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63868013230"},{"Id":409192,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63868013290"},{"Id":409193,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 1MG/ML","DosageForm":"SYRP - Syrup","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"63868013304"},{"Id":409194,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"63868013760"},{"Id":409195,"FormularyType":"OHP","DrugName":"QC SUPHEDRIN TAB 120MG SR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"63868014310"},{"Id":409196,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"63868015101"},{"Id":409197,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"63868015110"},{"Id":409198,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"63868015130"},{"Id":409199,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"63868015396"},{"Id":409200,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"63868015710"},{"Id":409201,"FormularyType":"OHP","DrugName":"TRAVEL EASE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"63868016316"},{"Id":409202,"FormularyType":"OHP","DrugName":"QC FIBER TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"63868016990"},{"Id":409203,"FormularyType":"OHP","DrugName":"PINK BISMUTH TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"63868017140"},{"Id":409204,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"63868017418"},{"Id":409205,"FormularyType":"OHP","DrugName":"QC ALCOHOL MIS WIPE 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"63868018540"},{"Id":409206,"FormularyType":"OHP","DrugName":"NON-ASPIRIN CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"63868018624"},{"Id":409207,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"63868019746"},{"Id":409208,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"63868019845"},{"Id":409209,"FormularyType":"OHP","DrugName":"QC CHILD ASA CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"63868024136"},{"Id":409210,"FormularyType":"OHP","DrugName":"QC SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"63868026301"},{"Id":409211,"FormularyType":"OHP","DrugName":"SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"63868026401"},{"Id":409212,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"63868026624"},{"Id":409213,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868026825"},{"Id":409214,"FormularyType":"OHP","DrugName":"QC GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"63868028325"},{"Id":409215,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"63868031012"},{"Id":409216,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"63868031410"},{"Id":409217,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868031510"},{"Id":409218,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868031560"},{"Id":409219,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB ACID RED","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"63868031925"},{"Id":409220,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB ACID RED","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"63868032030"},{"Id":409221,"FormularyType":"OHP","DrugName":"QC LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"63868032808"},{"Id":409222,"FormularyType":"OHP","DrugName":"QC LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"63868032825"},{"Id":409223,"FormularyType":"OHP","DrugName":"QC ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"63868033236"},{"Id":409224,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"63868033324"},{"Id":409225,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868034110"},{"Id":409226,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868034124"},{"Id":409227,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868034150"},{"Id":409228,"FormularyType":"OHP","DrugName":"QC NATURAL POW VEGETABL","DosageForm":"POWD - Powder","Strength":"95","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102995","GenericName":"PSYLLIUM POWDER 95%","NDC":"63868034718"},{"Id":409229,"FormularyType":"OHP","DrugName":"FIBER LAXTIV CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"63868034801"},{"Id":409230,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"63868035203"},{"Id":409231,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"63868035210"},{"Id":409232,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868036103"},{"Id":409233,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868036120"},{"Id":409234,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868036136"},{"Id":409235,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868036320"},{"Id":409236,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868036336"},{"Id":409237,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"63868036412"},{"Id":409238,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"63868037004"},{"Id":409239,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868037305"},{"Id":409240,"FormularyType":"OHP","DrugName":"QC ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"63868038045"},{"Id":409241,"FormularyType":"OHP","DrugName":"QC ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"63868038090"},{"Id":409242,"FormularyType":"OHP","DrugName":"QC APAP 8 HR TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868041201"},{"Id":409243,"FormularyType":"OHP","DrugName":"QC APAP 8 HR TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868041250"},{"Id":409244,"FormularyType":"OHP","DrugName":"QC APAP 8 HR TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868041350"},{"Id":409245,"FormularyType":"OHP","DrugName":"QC LORATADIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"63868041401"},{"Id":409246,"FormularyType":"OHP","DrugName":"ESOMEPRAZOLE CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"63868042514"},{"Id":409247,"FormularyType":"OHP","DrugName":"ESOMEPRAZOLE CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"63868042542"},{"Id":409248,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868042720"},{"Id":409249,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868042840"},{"Id":409250,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868042880"},{"Id":409251,"FormularyType":"OHP","DrugName":"QC TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"63868045905"},{"Id":409252,"FormularyType":"OHP","DrugName":"QC TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"63868045910"},{"Id":409253,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63868046936"},{"Id":409254,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868047020"},{"Id":409255,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868047048"},{"Id":409256,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868047080"},{"Id":409257,"FormularyType":"OHP","DrugName":"QC ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"63868047424"},{"Id":409258,"FormularyType":"OHP","DrugName":"QC HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"63868048501"},{"Id":409259,"FormularyType":"OHP","DrugName":"QC HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"63868048524"},{"Id":409260,"FormularyType":"OHP","DrugName":"QC HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"63868048550"},{"Id":409261,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"63868048625"},{"Id":409262,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"63868049210"},{"Id":409263,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"63868049224"},{"Id":409264,"FormularyType":"OHP","DrugName":"WOMANS LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"63868049930"},{"Id":409265,"FormularyType":"OHP","DrugName":"COMP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"63868050001"},{"Id":409266,"FormularyType":"OHP","DrugName":"COMP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"63868050024"},{"Id":409267,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868050701"},{"Id":409268,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"63868053090"},{"Id":409269,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868057001"},{"Id":409270,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868057050"},{"Id":409271,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868057101"},{"Id":409272,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868057150"},{"Id":409273,"FormularyType":"OHP","DrugName":"QC LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"63868057225"},{"Id":409274,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"63868057330"},{"Id":409275,"FormularyType":"OHP","DrugName":"QC VEGE LAXA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"63868057901"},{"Id":409276,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB ACID RED","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"63868058330"},{"Id":409277,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB ACID RED","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"63868058425"},{"Id":409278,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB ACID RED","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"63868058450"},{"Id":409279,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"63868058501"},{"Id":409280,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"63868058525"},{"Id":409281,"FormularyType":"OHP","DrugName":"QC ANTI-ITCH CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"63868059728"},{"Id":409282,"FormularyType":"OHP","DrugName":"NIGHT TIME TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"63868061132"},{"Id":409283,"FormularyType":"OHP","DrugName":"QC SLEEP AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"63868061232"},{"Id":409284,"FormularyType":"OHP","DrugName":"QC CHILDRENS CHW EXTRA C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"63868061660"},{"Id":409285,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"63868061701"},{"Id":409286,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"63868062660"},{"Id":409287,"FormularyType":"OHP","DrugName":"QC CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109903450350","GenericName":"*CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-400 UNIT***","NDC":"63868063060"},{"Id":409288,"FormularyType":"OHP","DrugName":"8HR ARTHRITS TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868066001"},{"Id":409289,"FormularyType":"OHP","DrugName":"8HR ARTHRITS TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868066050"},{"Id":409290,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"63868066201"},{"Id":409291,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63868066514"},{"Id":409292,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63868066530"},{"Id":409293,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63868066590"},{"Id":409294,"FormularyType":"OHP","DrugName":"QC ACETAMINO SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"63868067760"},{"Id":409295,"FormularyType":"OHP","DrugName":"QC ACETAMINO SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"63868067860"},{"Id":409296,"FormularyType":"OHP","DrugName":"QC 8 HR PAIN TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"63868067950"},{"Id":409297,"FormularyType":"OHP","DrugName":"QC ZINC OXID OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"63868068602"},{"Id":409298,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"63868068901"},{"Id":409299,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"63868069001"},{"Id":409300,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"63868069140"},{"Id":409301,"FormularyType":"OHP","DrugName":"QC ANTACID SUS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"63868069457"},{"Id":409302,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"63868070015"},{"Id":409303,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"63868070166"},{"Id":409304,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"63868070296"},{"Id":409305,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"63868070396"},{"Id":409306,"FormularyType":"OHP","DrugName":"QC ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"63868071257"},{"Id":409307,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"63868071430"},{"Id":409308,"FormularyType":"OHP","DrugName":"QC DICLOFENA GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"63868073001"},{"Id":409309,"FormularyType":"OHP","DrugName":"QC NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"63868073414"},{"Id":409310,"FormularyType":"OHP","DrugName":"QC NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"63868073514"},{"Id":409311,"FormularyType":"OHP","DrugName":"REST SIMPLY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"63868077210"},{"Id":409312,"FormularyType":"OHP","DrugName":"REST SIMPLY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"63868077224"},{"Id":409313,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868077305"},{"Id":409314,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868077310"},{"Id":409315,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868077324"},{"Id":409316,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868077350"},{"Id":409317,"FormularyType":"OHP","DrugName":"QC SLEEP-AID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"63868078424"},{"Id":409318,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"63868078757"},{"Id":409319,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"63868078857"},{"Id":409320,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868079001"},{"Id":409321,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868079101"},{"Id":409322,"FormularyType":"OHP","DrugName":"PSEUDOFED TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"63868080224"},{"Id":409323,"FormularyType":"OHP","DrugName":"PSEUDOFED TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"63868080248"},{"Id":409324,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"63868080540"},{"Id":409325,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"63868081912"},{"Id":409326,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"63868082125"},{"Id":409327,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"63868082354"},{"Id":409328,"FormularyType":"OHP","DrugName":"CHLOR-PHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"63868082601"},{"Id":409329,"FormularyType":"OHP","DrugName":"CHLOR-PHENIR TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"63868082624"},{"Id":409330,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"63868087501"},{"Id":409331,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"63868087860"},{"Id":409332,"FormularyType":"OHP","DrugName":"ENTERIC ASA TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"63868089810"},{"Id":409333,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN MAX ST","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"63868091001"},{"Id":409334,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN MULTI 1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"63868091201"},{"Id":409335,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"63868091410"},{"Id":409336,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868097910"},{"Id":409337,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868097924"},{"Id":409338,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868097950"},{"Id":409339,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868098303"},{"Id":409340,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868098309"},{"Id":409341,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868098324"},{"Id":409342,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63868098350"},{"Id":409343,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868098710"},{"Id":409344,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG/RR","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63868098750"},{"Id":409345,"FormularyType":"OHP","DrugName":"QC ALCOHOL PAD SWABS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"63868098903"},{"Id":409346,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"63868200202"},{"Id":409347,"FormularyType":"OHP","DrugName":"KLS QUIT2 GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"63981001247"},{"Id":409348,"FormularyType":"OHP","DrugName":"KLS QUIT2 GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"63981001287"},{"Id":409349,"FormularyType":"OHP","DrugName":"KLS QUIT2 LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"63981012409"},{"Id":409350,"FormularyType":"OHP","DrugName":"KLS QUIT2 LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"63981012437"},{"Id":409351,"FormularyType":"OHP","DrugName":"KLS QUIT4 GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"63981017001"},{"Id":409352,"FormularyType":"OHP","DrugName":"KLS QUIT4 GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"63981017056"},{"Id":409353,"FormularyType":"OHP","DrugName":"KLS QUIT4 LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"63981019009"},{"Id":409354,"FormularyType":"OHP","DrugName":"KLS QUIT4 LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"63981019037"},{"Id":409355,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"63981019485"},{"Id":409356,"FormularyType":"OHP","DrugName":"KLS IBUPROFN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63981029114"},{"Id":409357,"FormularyType":"OHP","DrugName":"LAXACLEAR POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"63981030604"},{"Id":409358,"FormularyType":"OHP","DrugName":"KLS QUIT4 GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"63981030947"},{"Id":409359,"FormularyType":"OHP","DrugName":"KLS QUIT4 GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"63981030987"},{"Id":409360,"FormularyType":"OHP","DrugName":"KLS ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"63981032978"},{"Id":409361,"FormularyType":"OHP","DrugName":"KLS QUIT2 LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"63981034409"},{"Id":409362,"FormularyType":"OHP","DrugName":"KLS QUIT2 LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"63981034437"},{"Id":409363,"FormularyType":"OHP","DrugName":"KLS IBUPROFN TAB IB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"63981039314"},{"Id":409364,"FormularyType":"OHP","DrugName":"ALLER-TEC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"63981045888"},{"Id":409365,"FormularyType":"OHP","DrugName":"ALLER-TEC SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"63981047543"},{"Id":409366,"FormularyType":"OHP","DrugName":"KLS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"63981056396"},{"Id":409367,"FormularyType":"OHP","DrugName":"KLS ARTHRITI GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"63981059905"},{"Id":409368,"FormularyType":"OHP","DrugName":"ALLERCLEAR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"63981061288"},{"Id":409369,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"63981070090"},{"Id":409370,"FormularyType":"OHP","DrugName":"KLS ARTHRITI GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"63981079905"},{"Id":409371,"FormularyType":"OHP","DrugName":"ALLER-FEX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"63981084748"},{"Id":409372,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"63981085340"},{"Id":409373,"FormularyType":"OHP","DrugName":"KLS QUIT4 LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"63981087309"},{"Id":409374,"FormularyType":"OHP","DrugName":"KLS QUIT4 LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"63981087337"},{"Id":409375,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"63981089803"},{"Id":409376,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"63981098696"},{"Id":409377,"FormularyType":"OHP","DrugName":"MELADOX TAB 3MG CR","DosageForm":"TBCR - Tablet ER","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000420","GenericName":"MELATONIN TAB ER 3 MG","NDC":"64038042303"},{"Id":409378,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"64125011610"},{"Id":409379,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"64125011701"},{"Id":409380,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"64125011710"},{"Id":409381,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"64125011801"},{"Id":409382,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"64125011805"},{"Id":409383,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"64125012701"},{"Id":409384,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"64125012710"},{"Id":409385,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"64125013001"},{"Id":409386,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"64125013010"},{"Id":409387,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"64125013110"},{"Id":409388,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"64125013601"},{"Id":409389,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"64125013610"},{"Id":409390,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"64125013701"},{"Id":409391,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"64125013710"},{"Id":409392,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"64125013801"},{"Id":409393,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"64125013810"},{"Id":409394,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"64253002030"},{"Id":409395,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"64253002091"},{"Id":409396,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002018","GenericName":"SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","NDC":"64253020230"},{"Id":409397,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"64380014901"},{"Id":409398,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(25MG)","DosageForm":"GEL - Gel","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004025","GenericName":"TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","NDC":"64380015101"},{"Id":409399,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(25MG)","DosageForm":"GEL - Gel","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004025","GenericName":"TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","NDC":"64380015102"},{"Id":409400,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"64380015201"},{"Id":409401,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"64380015202"},{"Id":409402,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"64380015301"},{"Id":409403,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100305","GenericName":"MEGESTROL ACETATE TAB 20 MG","NDC":"64380015801"},{"Id":409404,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100310","GenericName":"MEGESTROL ACETATE TAB 40 MG","NDC":"64380015901"},{"Id":409405,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100310","GenericName":"MEGESTROL ACETATE TAB 40 MG","NDC":"64380015902"},{"Id":409406,"FormularyType":"OHP","DrugName":"MEGESTROL AC TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020100310","GenericName":"MEGESTROL ACETATE TAB 40 MG","NDC":"64380015903"},{"Id":409407,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"64380016001"},{"Id":409408,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"64380016002"},{"Id":409409,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"64380016101"},{"Id":409410,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64380016201"},{"Id":409411,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64380016202"},{"Id":409412,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64380016203"},{"Id":409413,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000330","GenericName":"PROPAFENONE HCL TAB 300 MG","NDC":"64380016301"},{"Id":409414,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000325","GenericName":"PROPAFENONE HCL TAB 225 MG","NDC":"64380016401"},{"Id":409415,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000325","GenericName":"PROPAFENONE HCL TAB 225 MG","NDC":"64380016402"},{"Id":409416,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000320","GenericName":"PROPAFENONE HCL TAB 150 MG","NDC":"64380016501"},{"Id":409417,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000320","GenericName":"PROPAFENONE HCL TAB 150 MG","NDC":"64380016502"},{"Id":409418,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"64380016601"},{"Id":409419,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"64380016702"},{"Id":409420,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"64380016802"},{"Id":409421,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000105","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 50 MG","NDC":"64380017901"},{"Id":409422,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"64380018001"},{"Id":409423,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"64380018002"},{"Id":409424,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000310","GenericName":"ZAFIRLUKAST TAB 10 MG","NDC":"64380018701"},{"Id":409425,"FormularyType":"OHP","DrugName":"ZAFIRLUKAST TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505080000320","GenericName":"ZAFIRLUKAST TAB 20 MG","NDC":"64380018801"},{"Id":409426,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000305","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 50 MG","NDC":"64380020501"},{"Id":409427,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"64380020701"},{"Id":409428,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"64380021201"},{"Id":409429,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"64380021202"},{"Id":409430,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"64380021301"},{"Id":409431,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"64380024301"},{"Id":409432,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"64380024401"},{"Id":409433,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000330","GenericName":"PROPAFENONE HCL TAB 300 MG","NDC":"64380024601"},{"Id":409434,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"64380025901"},{"Id":409435,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"64380026001"},{"Id":409436,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"64380026101"},{"Id":409437,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"64380026201"},{"Id":409438,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"64380026301"},{"Id":409439,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000325","GenericName":"PROPAFENONE HCL TAB 225 MG","NDC":"64380026801"},{"Id":409440,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 225MG","DosageForm":"TABS - Tablet","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000325","GenericName":"PROPAFENONE HCL TAB 225 MG","NDC":"64380026802"},{"Id":409441,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000320","GenericName":"PROPAFENONE HCL TAB 150 MG","NDC":"64380026901"},{"Id":409442,"FormularyType":"OHP","DrugName":"PROPAFENONE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300050000320","GenericName":"PROPAFENONE HCL TAB 150 MG","NDC":"64380026902"},{"Id":409443,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"64380044001"},{"Id":409444,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"64380044101"},{"Id":409445,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"64380044201"},{"Id":409446,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"64380044601"},{"Id":409447,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"64380044701"},{"Id":409448,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050310","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","NDC":"64380044801"},{"Id":409449,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"64380071003"},{"Id":409450,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000330","GenericName":"LAMIVUDINE TAB 300 MG","NDC":"64380071104"},{"Id":409451,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"64380071206"},{"Id":409452,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"64380071207"},{"Id":409453,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"64380071306"},{"Id":409454,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"64380071307"},{"Id":409455,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"64380071404"},{"Id":409456,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"64380071904"},{"Id":409457,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"64380072006"},{"Id":409458,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"64380072106"},{"Id":409459,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"64380072206"},{"Id":409460,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"64380072304"},{"Id":409461,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"64380072306"},{"Id":409462,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.5MCG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000110","GenericName":"CALCITRIOL CAP 0.5 MCG","NDC":"64380072406"},{"Id":409463,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"64380072506"},{"Id":409464,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"64380072507"},{"Id":409465,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"64380072606"},{"Id":409466,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"64380072607"},{"Id":409467,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"64380072701"},{"Id":409468,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"64380072702"},{"Id":409469,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"64380072801"},{"Id":409470,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"64380072802"},{"Id":409471,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"64380072901"},{"Id":409472,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"64380072902"},{"Id":409473,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100110","GenericName":"VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"64380072903"},{"Id":409474,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"64380073001"},{"Id":409475,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"64380073002"},{"Id":409476,"FormularyType":"OHP","DrugName":"VANCOMYCIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080100120","GenericName":"VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","NDC":"64380073003"},{"Id":409477,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"64380073101"},{"Id":409478,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"64380073102"},{"Id":409479,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"64380073406"},{"Id":409480,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"64380073408"},{"Id":409481,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"64380073506"},{"Id":409482,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"64380073508"},{"Id":409483,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"64380073606"},{"Id":409484,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"64380073706"},{"Id":409485,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"64380074001"},{"Id":409486,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6/0.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"64380074002"},{"Id":409487,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"64380074605"},{"Id":409488,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"64380074705"},{"Id":409489,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"64380074805"},{"Id":409490,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"64380074905"},{"Id":409491,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"64380075005"},{"Id":409492,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"64380075105"},{"Id":409493,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"64380075301"},{"Id":409494,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"64380075302"},{"Id":409495,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"64380075401"},{"Id":409496,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"64380075402"},{"Id":409497,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000310","GenericName":"ACARBOSE TAB 25 MG","NDC":"64380075806"},{"Id":409498,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000320","GenericName":"ACARBOSE TAB 50 MG","NDC":"64380075906"},{"Id":409499,"FormularyType":"OHP","DrugName":"ACARBOSE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ALPHA-GLUCOSIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27500010000340","GenericName":"ACARBOSE TAB 100 MG","NDC":"64380076006"},{"Id":409500,"FormularyType":"OHP","DrugName":"PEG-3350 SOL ELECTROL","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992005302130","GenericName":"PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM","NDC":"64380076621"},{"Id":409501,"FormularyType":"OHP","DrugName":"PEG-3350/KCL SOL /SODIUM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46992004302120","GenericName":"PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM","NDC":"64380076921"},{"Id":409502,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64380078108"},{"Id":409503,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"64380078206"},{"Id":409504,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"64380078306"},{"Id":409505,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"64380078308"},{"Id":409506,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"64380078406"},{"Id":409507,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"64380078407"},{"Id":409508,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"64380078408"},{"Id":409509,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"64380078506"},{"Id":409510,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"64380078507"},{"Id":409511,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"64380078508"},{"Id":409512,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"64380079506"},{"Id":409513,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"64380079508"},{"Id":409514,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"64380079604"},{"Id":409515,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"64380079606"},{"Id":409516,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"64380079701"},{"Id":409517,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"64380079801"},{"Id":409518,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"64380079901"},{"Id":409519,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"64380080706"},{"Id":409520,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"64380080707"},{"Id":409521,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"64380080806"},{"Id":409522,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"64380080807"},{"Id":409523,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"64380080906"},{"Id":409524,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"64380080907"},{"Id":409525,"FormularyType":"OHP","DrugName":"KETOCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11404040000310","GenericName":"KETOCONAZOLE TAB 200 MG","NDC":"64380082706"},{"Id":409526,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"64380083306"},{"Id":409527,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"64380083406"},{"Id":409528,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"64380083506"},{"Id":409529,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"64380084406"},{"Id":409530,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"64380086006"},{"Id":409531,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"64380086007"},{"Id":409532,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"64380086008"},{"Id":409533,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"64380086106"},{"Id":409534,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"64380086107"},{"Id":409535,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"64380086108"},{"Id":409536,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"64380086706"},{"Id":409537,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"64380086707"},{"Id":409538,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"64380086806"},{"Id":409539,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"64380086807"},{"Id":409540,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"64380086906"},{"Id":409541,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"64380086907"},{"Id":409542,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"64380087267"},{"Id":409543,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010000105","GenericName":"ETHOSUXIMIDE CAP 250 MG","NDC":"64380087806"},{"Id":409544,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"64380087975"},{"Id":409545,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"64380088000"},{"Id":409546,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"64380088080"},{"Id":409547,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"64380088100"},{"Id":409548,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"64380088180"},{"Id":409549,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"64380088304"},{"Id":409550,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"64380088404"},{"Id":409551,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"64380088504"},{"Id":409552,"FormularyType":"OHP","DrugName":"URSODIOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000325","GenericName":"URSODIOL TAB 250 MG","NDC":"64380091806"},{"Id":409553,"FormularyType":"OHP","DrugName":"URSODIOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000350","GenericName":"URSODIOL TAB 500 MG","NDC":"64380091906"},{"Id":409554,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000105","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 50 MG","NDC":"64380092001"},{"Id":409555,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"64380092201"},{"Id":409556,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"64380092202"},{"Id":409557,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"64380093304"},{"Id":409558,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"64380093305"},{"Id":409559,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"64380093308"},{"Id":409560,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"64380093404"},{"Id":409561,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"64380093405"},{"Id":409562,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"64380093408"},{"Id":409563,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"64380093504"},{"Id":409564,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"64380093505"},{"Id":409565,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"64380093508"},{"Id":409566,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"64380094906"},{"Id":409567,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"64380097025"},{"Id":409568,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"64380097106"},{"Id":409569,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"64380097206"},{"Id":409570,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"64380099703"},{"Id":409571,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"64380099704"},{"Id":409572,"FormularyType":"OHP","DrugName":"SKYCLARYS CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"FRIEDRICH'S ATAXIA AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74135060000120","GenericName":"OMAVELOXOLONE CAP 50 MG","NDC":"64406025090"},{"Id":409573,"FormularyType":"OHP","DrugName":"CFPREOP LIQ GRAPE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"64446000020"},{"Id":409574,"FormularyType":"OHP","DrugName":"LYTGOBI TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153222800B720","GenericName":"FUTIBATINIB TAB THERAPY PACK 4 MG (12 MG DAILY DOSE)","NDC":"64842012004"},{"Id":409575,"FormularyType":"OHP","DrugName":"LYTGOBI TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153222800B725","GenericName":"FUTIBATINIB TAB THERAPY PACK 4 MG (16 MG DAILY DOSE)","NDC":"64842012005"},{"Id":409576,"FormularyType":"OHP","DrugName":"LYTGOBI TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2153222800B730","GenericName":"FUTIBATINIB TAB THERAPY PACK 4 MG (20 MG DAILY DOSE)","NDC":"64842012006"},{"Id":409577,"FormularyType":"OHP","DrugName":"INQOVI TAB 35-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002250320","GenericName":"DECITABINE-CEDAZURIDINE TAB 35-100 MG","NDC":"64842072709"},{"Id":409578,"FormularyType":"OHP","DrugName":"LONSURF TAB 20-8.19","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002750330","GenericName":"TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG","NDC":"64842102001"},{"Id":409579,"FormularyType":"OHP","DrugName":"LONSURF TAB 20-8.19","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002750330","GenericName":"TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG","NDC":"64842102002"},{"Id":409580,"FormularyType":"OHP","DrugName":"LONSURF TAB 20-8.19","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002750330","GenericName":"TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG","NDC":"64842102003"},{"Id":409581,"FormularyType":"OHP","DrugName":"LONSURF TAB 15-6.14","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002750320","GenericName":"TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG","NDC":"64842102501"},{"Id":409582,"FormularyType":"OHP","DrugName":"LONSURF TAB 15-6.14","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002750320","GenericName":"TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG","NDC":"64842102502"},{"Id":409583,"FormularyType":"OHP","DrugName":"LONSURF TAB 15-6.14","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21990002750320","GenericName":"TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG","NDC":"64842102503"},{"Id":409584,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"64850030001"},{"Id":409585,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"64850030030"},{"Id":409586,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"64850033001"},{"Id":409587,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"64850050001"},{"Id":409588,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"64850050101"},{"Id":409589,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"64850050201"},{"Id":409590,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"64850050301"},{"Id":409591,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"64850050401"},{"Id":409592,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"64850050501"},{"Id":409593,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"64850050601"},{"Id":409594,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"64850051001"},{"Id":409595,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"64850051101"},{"Id":409596,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"64850051201"},{"Id":409597,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"64850051301"},{"Id":409598,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"64850051401"},{"Id":409599,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"64850051501"},{"Id":409600,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"64850055001"},{"Id":409601,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"64850055101"},{"Id":409602,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"64850055201"},{"Id":409603,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"64850055301"},{"Id":409604,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"64850055401"},{"Id":409605,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"64850055501"},{"Id":409606,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"64850055601"},{"Id":409607,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"64850062101"},{"Id":409608,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"64850062201"},{"Id":409609,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"64850062301"},{"Id":409610,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"64850063101"},{"Id":409611,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"64850063105"},{"Id":409612,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"64850063201"},{"Id":409613,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"64850063205"},{"Id":409614,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"64850063301"},{"Id":409615,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"64850063305"},{"Id":409616,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050310","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","NDC":"64850064101"},{"Id":409617,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050310","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","NDC":"64850064105"},{"Id":409618,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"64850064201"},{"Id":409619,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"64850064205"},{"Id":409620,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"64850064301"},{"Id":409621,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"64850064305"},{"Id":409622,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100105","GenericName":"DANTROLENE SODIUM CAP 25 MG","NDC":"64850084001"},{"Id":409623,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100110","GenericName":"DANTROLENE SODIUM CAP 50 MG","NDC":"64850084101"},{"Id":409624,"FormularyType":"OHP","DrugName":"DANTROLENE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"DIRECT MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75200010100115","GenericName":"DANTROLENE SODIUM CAP 100 MG","NDC":"64850084201"},{"Id":409625,"FormularyType":"OHP","DrugName":"MIFEPREX TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"O","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROGESTERONE RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30502060000320","GenericName":"MIFEPRISTONE TAB 200 MG","NDC":"64875000101"},{"Id":409626,"FormularyType":"OHP","DrugName":"RENTHYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"64950017001"},{"Id":409627,"FormularyType":"OHP","DrugName":"RENTHYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"64950017101"},{"Id":409628,"FormularyType":"OHP","DrugName":"RENTHYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"64950017201"},{"Id":409629,"FormularyType":"OHP","DrugName":"RENTHYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"64950017301"},{"Id":409630,"FormularyType":"OHP","DrugName":"RENTHYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"64950017401"},{"Id":409631,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000305","GenericName":"ISONIAZID TAB 100 MG","NDC":"64950021610"},{"Id":409632,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"64950021703"},{"Id":409633,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"64950021710"},{"Id":409634,"FormularyType":"OHP","DrugName":"FLURBIPROFEN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"M","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100012000315","GenericName":"FLURBIPROFEN TAB 100 MG","NDC":"64950021810"},{"Id":409635,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"64950034316"},{"Id":409636,"FormularyType":"OHP","DrugName":"METOCLOPRAM SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102013","GenericName":"METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","NDC":"64950034416"},{"Id":409637,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"64950035405"},{"Id":409638,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"64950035445"},{"Id":409639,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"64950035450"},{"Id":409640,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"64950035455"},{"Id":409641,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"64950037316"},{"Id":409642,"FormularyType":"OHP","DrugName":"APAP/CODEINE SOL 120-12/5","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002052020","GenericName":"ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML","NDC":"64950037416"},{"Id":409643,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100012102020","GenericName":"CIPROFLOXACIN HCL OTIC SOLN 0.2% (BASE EQUIVALENT)","NDC":"64950038114"},{"Id":409644,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"64950057101"},{"Id":409645,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"64950057110"},{"Id":409646,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"64950057201"},{"Id":409647,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"64950057210"},{"Id":409648,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"64950057301"},{"Id":409649,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"64950057310"},{"Id":409650,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"64950057401"},{"Id":409651,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"64950057410"},{"Id":409652,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"64950057501"},{"Id":409653,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"64950057510"},{"Id":409654,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"64950057601"},{"Id":409655,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"64950057610"},{"Id":409656,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"64950057701"},{"Id":409657,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"64950057710"},{"Id":409658,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"64950057801"},{"Id":409659,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"64950057810"},{"Id":409660,"FormularyType":"OHP","DrugName":"PHOSPHA 250 TAB NEUTRAL","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"PHOSPHATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79600030100320","GenericName":"POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG","NDC":"64980010401"},{"Id":409661,"FormularyType":"OHP","DrugName":"CHLOROQUINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000010200305","GenericName":"CHLOROQUINE PHOSPHATE TAB 250 MG","NDC":"64980017750"},{"Id":409662,"FormularyType":"OHP","DrugName":"CHLOROQUINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000010200310","GenericName":"CHLOROQUINE PHOSPHATE TAB 500 MG","NDC":"64980017802"},{"Id":409663,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"64980020901"},{"Id":409664,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"64980020905"},{"Id":409665,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"64980021001"},{"Id":409666,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"64980021005"},{"Id":409667,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"64980021101"},{"Id":409668,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI TAB ER 180MG","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100405","GenericName":"PYRIDOSTIGMINE BROMIDE TAB ER 180 MG","NDC":"64980022003"},{"Id":409669,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"64980026401"},{"Id":409670,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"64980026501"},{"Id":409671,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 2.5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007505","GenericName":"GLIPIZIDE TAB ER 24HR 2.5 MG","NDC":"64980027903"},{"Id":409672,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"64980028001"},{"Id":409673,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"64980028005"},{"Id":409674,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 5MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007510","GenericName":"GLIPIZIDE TAB ER 24HR 5 MG","NDC":"64980028010"},{"Id":409675,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"64980028101"},{"Id":409676,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"64980028105"},{"Id":409677,"FormularyType":"OHP","DrugName":"GLIPIZIDE ER TAB 10MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030007520","GenericName":"GLIPIZIDE TAB ER 24HR 10 MG","NDC":"64980028110"},{"Id":409678,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"64980028203"},{"Id":409679,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"64980030301"},{"Id":409680,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"64980030310"},{"Id":409681,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"64980030401"},{"Id":409682,"FormularyType":"OHP","DrugName":"MAGNESIUM-OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"64980033901"},{"Id":409683,"FormularyType":"OHP","DrugName":"MAGNESIUM-OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"64980033912"},{"Id":409684,"FormularyType":"OHP","DrugName":"MAGNESIUM-OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"64980033990"},{"Id":409685,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"64980034001"},{"Id":409686,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"64980034003"},{"Id":409687,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"64980034114"},{"Id":409688,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"64980034201"},{"Id":409689,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"64980034214"},{"Id":409690,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000305","GenericName":"FAMCICLOVIR TAB 125 MG","NDC":"64980034903"},{"Id":409691,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000310","GenericName":"FAMCICLOVIR TAB 250 MG","NDC":"64980035003"},{"Id":409692,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000320","GenericName":"FAMCICLOVIR TAB 500 MG","NDC":"64980035103"},{"Id":409693,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101930","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","NDC":"64980040310"},{"Id":409694,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101930","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","NDC":"64980040350"},{"Id":409695,"FormularyType":"OHP","DrugName":"TOREMIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402685100320","GenericName":"TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT)","NDC":"64980040403"},{"Id":409696,"FormularyType":"OHP","DrugName":"ABACAVIR SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005102020","GenericName":"ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV)","NDC":"64980040524"},{"Id":409697,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"64980041009"},{"Id":409698,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"64980041109"},{"Id":409699,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"64980041110"},{"Id":409700,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"64980041209"},{"Id":409701,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"64980041210"},{"Id":409702,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"64980041309"},{"Id":409703,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"64980041310"},{"Id":409704,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"64980041409"},{"Id":409705,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"64980041410"},{"Id":409706,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"64980041509"},{"Id":409707,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"64980041609"},{"Id":409708,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"64980041709"},{"Id":409709,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"64980041812"},{"Id":409710,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64980043101"},{"Id":409711,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64980043110"},{"Id":409712,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"64980043150"},{"Id":409713,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"64980043201"},{"Id":409714,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"64980043205"},{"Id":409715,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"64980043301"},{"Id":409716,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"64980043401"},{"Id":409717,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"64980043501"},{"Id":409718,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"64980043701"},{"Id":409719,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"64980043710"},{"Id":409720,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"64980043801"},{"Id":409721,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"64980043810"},{"Id":409722,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"64980043901"},{"Id":409723,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"64980043910"},{"Id":409724,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"64980044201"},{"Id":409725,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"64980044301"},{"Id":409726,"FormularyType":"OHP","DrugName":"CALCITRIOL SOL 1MCG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030002050","GenericName":"CALCITRIOL ORAL SOLN 1 MCG/ML","NDC":"64980044715"},{"Id":409727,"FormularyType":"OHP","DrugName":"NEO/POLY/HC SUS 1% OTIC","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991003101807","GenericName":"NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%","NDC":"64980044801"},{"Id":409728,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"64980044903"},{"Id":409729,"FormularyType":"OHP","DrugName":"LEVOCARNITIN SOL 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045102010","GenericName":"LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)","NDC":"64980050312"},{"Id":409730,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"64980050448"},{"Id":409731,"FormularyType":"OHP","DrugName":"DEXAMETHASON ELX 0.5/5ML","DosageForm":"ELIX - Elixir","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020001005","GenericName":"DEXAMETHASONE ELIXIR 0.5 MG/5ML","NDC":"64980050924"},{"Id":409732,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"64980051110"},{"Id":409733,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"64980051301"},{"Id":409734,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"64980051305"},{"Id":409735,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"64980051315"},{"Id":409736,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"64980051401"},{"Id":409737,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"64980051405"},{"Id":409738,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"64980051415"},{"Id":409739,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"64980051501"},{"Id":409740,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"64980051505"},{"Id":409741,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"64980051625"},{"Id":409742,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"64980052810"},{"Id":409743,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"64980056102"},{"Id":409744,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"64980056103"},{"Id":409745,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"64980056201"},{"Id":409746,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"64980056210"},{"Id":409747,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"64980056301"},{"Id":409748,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"64980056310"},{"Id":409749,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"64980056401"},{"Id":409750,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"64980056450"},{"Id":409751,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"64980056601"},{"Id":409752,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"64980056603"},{"Id":409753,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"64980056701"},{"Id":409754,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"64980056703"},{"Id":409755,"FormularyType":"OHP","DrugName":"METHYLDOPA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201030000310","GenericName":"METHYLDOPA TAB 250 MG","NDC":"64980057101"},{"Id":409756,"FormularyType":"OHP","DrugName":"METHYLDOPA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201030000315","GenericName":"METHYLDOPA TAB 500 MG","NDC":"64980057201"},{"Id":409757,"FormularyType":"OHP","DrugName":"PHENYTOIN CHW 50MG","DosageForm":"CHEW - Tablet Chewable","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030000505","GenericName":"PHENYTOIN CHEW TAB 50 MG","NDC":"64980057301"},{"Id":409758,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"64980058206"},{"Id":409759,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10GM/15","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"64980059248"},{"Id":409760,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10GM/15","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"64980059295"},{"Id":409761,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"64980059901"},{"Id":409762,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"64980059910"},{"Id":409763,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"64980060001"},{"Id":409764,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"64980060203"},{"Id":409765,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"64980060209"},{"Id":409766,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"64980060303"},{"Id":409767,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"64980060309"},{"Id":409768,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"64980060412"},{"Id":409769,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"64980060450"},{"Id":409770,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"64980060512"},{"Id":409771,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"64980060550"},{"Id":409772,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"64980060612"},{"Id":409773,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"64980060650"},{"Id":409774,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"64980060706"},{"Id":409775,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"64980061401"},{"Id":409776,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"64980061410"},{"Id":409777,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"64980061450"},{"Id":409778,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"64980062301"},{"Id":409779,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"64980062310"},{"Id":409780,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"64980062350"},{"Id":409781,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"64980062401"},{"Id":409782,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"64980062410"},{"Id":409783,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"64980062450"},{"Id":409784,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"64980063203"},{"Id":409785,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"64980063209"},{"Id":409786,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"64980063210"},{"Id":409787,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"64980063303"},{"Id":409788,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"64980063309"},{"Id":409789,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"64980063310"},{"Id":409790,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"64980063401"},{"Id":409791,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"64980063450"},{"Id":409792,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"64980063501"},{"Id":409793,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"64980063550"},{"Id":409794,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"64980063803"},{"Id":409795,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"64980063903"},{"Id":409796,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"64980064002"},{"Id":409797,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"64980064003"},{"Id":409798,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"64980064006"},{"Id":409799,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.5%","DosageForm":"NEBU - Nebulization solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102520","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)","NDC":"64980064203"},{"Id":409800,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"64980064503"},{"Id":409801,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"64980064506"},{"Id":409802,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"64980065501"},{"Id":409803,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"64980065510"},{"Id":409804,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"64980065550"},{"Id":409805,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"64980065701"},{"Id":409806,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"64980065710"},{"Id":409807,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"64980065750"},{"Id":409808,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"64980065810"},{"Id":409809,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"64980065815"},{"Id":409810,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"64980065910"},{"Id":409811,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"64980065915"},{"Id":409812,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"64980066027"},{"Id":409813,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"64980066036"},{"Id":409814,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"64980066091"},{"Id":409815,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"64980066127"},{"Id":409816,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"64980066136"},{"Id":409817,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"64980066191"},{"Id":409818,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"64980066227"},{"Id":409819,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"64980066236"},{"Id":409820,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"64980066291"},{"Id":409821,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"64980066503"},{"Id":409822,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"64980066509"},{"Id":409823,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100105","GenericName":"MEXILETINE HCL CAP 150 MG","NDC":"64980066601"},{"Id":409824,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100110","GenericName":"MEXILETINE HCL CAP 200 MG","NDC":"64980066701"},{"Id":409825,"FormularyType":"OHP","DrugName":"MEXILETINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-B","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35200025100115","GenericName":"MEXILETINE HCL CAP 250 MG","NDC":"64980066801"},{"Id":409826,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"64980067609"},{"Id":409827,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"64980067709"},{"Id":409828,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"64980067710"},{"Id":409829,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"64980068501"},{"Id":409830,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"64980068510"},{"Id":409831,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"64980068601"},{"Id":409832,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"64980068610"},{"Id":409833,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"64980068701"},{"Id":409834,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"64980068710"},{"Id":409835,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"64980068801"},{"Id":409836,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"64980068810"},{"Id":409837,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"64980070601"},{"Id":409838,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"64980070650"},{"Id":409839,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"64980070701"},{"Id":409840,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"64980070750"},{"Id":409841,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"64980070801"},{"Id":409842,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"64980070850"},{"Id":409843,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"64980070901"},{"Id":409844,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"64980070903"},{"Id":409845,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"64980071001"},{"Id":409846,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"64980071003"},{"Id":409847,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"65145011301"},{"Id":409848,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"65145011325"},{"Id":409849,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6/0.5ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"65145011801"},{"Id":409850,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6/0.5ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"65145011805"},{"Id":409851,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"65145013901"},{"Id":409852,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"65145014001"},{"Id":409853,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"65145014101"},{"Id":409854,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"65145014201"},{"Id":409855,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"65145014301"},{"Id":409856,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"65145014401"},{"Id":409857,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"65145015201"},{"Id":409858,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"65145015301"},{"Id":409859,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"65145015401"},{"Id":409860,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"65145015501"},{"Id":409861,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"65145015510"},{"Id":409862,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1GM/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102020","GenericName":"PROCAINAMIDE HCL INJ 500 MG/ML","NDC":"65145015601"},{"Id":409863,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 1GM/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102020","GenericName":"PROCAINAMIDE HCL INJ 500 MG/ML","NDC":"65145015610"},{"Id":409864,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"65155070301"},{"Id":409865,"FormularyType":"OHP","DrugName":"CALCIUM PLS TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"65155074206"},{"Id":409866,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"65162002309"},{"Id":409867,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"65162002409"},{"Id":409868,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"65162002509"},{"Id":409869,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"65162002609"},{"Id":409870,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"65162002709"},{"Id":409871,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"65162002809"},{"Id":409872,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"65162003310"},{"Id":409873,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"65162003311"},{"Id":409874,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"65162004710"},{"Id":409875,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100310","GenericName":"OXYCODONE HCL TAB 5 MG","NDC":"65162004750"},{"Id":409876,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100320","GenericName":"OXYCODONE HCL TAB 10 MG","NDC":"65162004810"},{"Id":409877,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"65162004910"},{"Id":409878,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"65162004950"},{"Id":409879,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100330","GenericName":"OXYCODONE HCL TAB 20 MG","NDC":"65162005010"},{"Id":409880,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"65162005110"},{"Id":409881,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"65162005703"},{"Id":409882,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"65162005710"},{"Id":409883,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"65162005827"},{"Id":409884,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"65162006205"},{"Id":409885,"FormularyType":"OHP","DrugName":"ITRACONAZOLE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407035002020","GenericName":"ITRACONAZOLE ORAL SOLN 10 MG/ML","NDC":"65162008774"},{"Id":409886,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"65162010110"},{"Id":409887,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"65162010111"},{"Id":409888,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"65162010150"},{"Id":409889,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"65162010210"},{"Id":409890,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"65162010211"},{"Id":409891,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"65162010250"},{"Id":409892,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"65162010310"},{"Id":409893,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"65162010350"},{"Id":409894,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"65162011510"},{"Id":409895,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"65162011511"},{"Id":409896,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"65162011550"},{"Id":409897,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"65162012604"},{"Id":409898,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"65162012608"},{"Id":409899,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"65162014804"},{"Id":409900,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"65162014808"},{"Id":409901,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"65162014904"},{"Id":409902,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"65162014908"},{"Id":409903,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"65162015004"},{"Id":409904,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"65162015008"},{"Id":409905,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"65162016906"},{"Id":409906,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"65162017306"},{"Id":409907,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"65162018810"},{"Id":409908,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"65162018850"},{"Id":409909,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"65162018910"},{"Id":409910,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"65162018950"},{"Id":409911,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"65162019010"},{"Id":409912,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"65162019011"},{"Id":409913,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"65162019050"},{"Id":409914,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"65162020710"},{"Id":409915,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"65162020750"},{"Id":409916,"FormularyType":"OHP","DrugName":"YUVAFEM TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"65162022621"},{"Id":409917,"FormularyType":"OHP","DrugName":"YUVAFEM TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"65162022623"},{"Id":409918,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"65162022804"},{"Id":409919,"FormularyType":"OHP","DrugName":"LYLLANA DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"65162022808"},{"Id":409920,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"65162024709"},{"Id":409921,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"65162025009"},{"Id":409922,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"65162027110"},{"Id":409923,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"65162027150"},{"Id":409924,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"65162027210"},{"Id":409925,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"65162027250"},{"Id":409926,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 500MG","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000450","GenericName":"NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","NDC":"65162032109"},{"Id":409927,"FormularyType":"OHP","DrugName":"NIACIN ER TAB 1000MG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"NICOTINIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39450050000470","GenericName":"NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","NDC":"65162032309"},{"Id":409928,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"65162035109"},{"Id":409929,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"65162035111"},{"Id":409930,"FormularyType":"OHP","DrugName":"ZAFEMY DIS 150/35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"65162035801"},{"Id":409931,"FormularyType":"OHP","DrugName":"ZAFEMY DIS 150/35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"65162035803"},{"Id":409932,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 800MG DR","DosageForm":"TBEC - Tablet DR","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000650","GenericName":"MESALAMINE TAB DELAYED RELEASE 800 MG","NDC":"65162036018"},{"Id":409933,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"65162036110"},{"Id":409934,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"65162036111"},{"Id":409935,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"65162037110"},{"Id":409936,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 8-2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200740","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","NDC":"65162041503"},{"Id":409937,"FormularyType":"OHP","DrugName":"BUPREN/NALOX SUB 2-0.5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010200720","GenericName":"BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","NDC":"65162041603"},{"Id":409938,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"65162044110"},{"Id":409939,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"65162044111"},{"Id":409940,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"65162044210"},{"Id":409941,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"65162044211"},{"Id":409942,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"65162046410"},{"Id":409943,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"65162046450"},{"Id":409944,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"65162046510"},{"Id":409945,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"65162046550"},{"Id":409946,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"65162046609"},{"Id":409947,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"65162046610"},{"Id":409948,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"65162046650"},{"Id":409949,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"65162046819"},{"Id":409950,"FormularyType":"OHP","DrugName":"ELURYNG MIS","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"65162046932"},{"Id":409951,"FormularyType":"OHP","DrugName":"ELURYNG MIS","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"65162046935"},{"Id":409952,"FormularyType":"OHP","DrugName":"NORETHIN ACE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000030100305","GenericName":"NORETHINDRONE ACETATE TAB 5 MG","NDC":"65162047505"},{"Id":409953,"FormularyType":"OHP","DrugName":"NORETHIN ACE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000030100305","GenericName":"NORETHINDRONE ACETATE TAB 5 MG","NDC":"65162047509"},{"Id":409954,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"65162051210"},{"Id":409955,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"65162051250"},{"Id":409956,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"65162051310"},{"Id":409957,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"65162051350"},{"Id":409958,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"65162052110"},{"Id":409959,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"65162052111"},{"Id":409960,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100315","GenericName":"PROMETHAZINE HCL TAB 50 MG","NDC":"65162052210"},{"Id":409961,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100310","GenericName":"BETHANECHOL CHLORIDE TAB 5 MG","NDC":"65162057110"},{"Id":409962,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100320","GenericName":"BETHANECHOL CHLORIDE TAB 10 MG","NDC":"65162057210"},{"Id":409963,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100330","GenericName":"BETHANECHOL CHLORIDE TAB 25 MG","NDC":"65162057310"},{"Id":409964,"FormularyType":"OHP","DrugName":"BETHANECHOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54300010100340","GenericName":"BETHANECHOL CHLORIDE TAB 50 MG","NDC":"65162057410"},{"Id":409965,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"65162059606"},{"Id":409966,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"65162062710"},{"Id":409967,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"65162062711"},{"Id":409968,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"65162062750"},{"Id":409969,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"65162063003"},{"Id":409970,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"65162063609"},{"Id":409971,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"65162063709"},{"Id":409972,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"65162063711"},{"Id":409973,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"65162064978"},{"Id":409974,"FormularyType":"OHP","DrugName":"PRENATAL TAB PLUS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"65162066810"},{"Id":409975,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"65162067684"},{"Id":409976,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100305","GenericName":"PHENAZOPYRIDINE HCL TAB 100 MG","NDC":"65162068110"},{"Id":409977,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100310","GenericName":"PHENAZOPYRIDINE HCL TAB 200 MG","NDC":"65162068210"},{"Id":409978,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"65162068688"},{"Id":409979,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"65162068690"},{"Id":409980,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"65162069179"},{"Id":409981,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"65162069388"},{"Id":409982,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"65162069890"},{"Id":409983,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"65162071003"},{"Id":409984,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"65162071009"},{"Id":409985,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"65162071110"},{"Id":409986,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"65162071310"},{"Id":409987,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"65162073409"},{"Id":409988,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"65162073509"},{"Id":409989,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"65162073518"},{"Id":409990,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100305","GenericName":"PROMETHAZINE HCL TAB 12.5 MG","NDC":"65162074510"},{"Id":409991,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"65162075009"},{"Id":409992,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"65162075110"},{"Id":409993,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100310","GenericName":"BENAZEPRIL HCL TAB 5 MG","NDC":"65162075150"},{"Id":409994,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"65162075210"},{"Id":409995,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100320","GenericName":"BENAZEPRIL HCL TAB 10 MG","NDC":"65162075250"},{"Id":409996,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"65162075310"},{"Id":409997,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"65162075350"},{"Id":409998,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"65162075410"},{"Id":409999,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"65162075450"},{"Id":410000,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"65162076110"},{"Id":410001,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"65162076111"},{"Id":410002,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"65162076210"},{"Id":410003,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"65162076211"},{"Id":410004,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"65162076310"},{"Id":410005,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"65162076311"},{"Id":410006,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"65162076410"},{"Id":410007,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"65162076411"},{"Id":410008,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"65162076510"},{"Id":410009,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"65162076511"},{"Id":410010,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"65162076610"},{"Id":410011,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"65162076611"},{"Id":410012,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"65162076710"},{"Id":410013,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"65162076711"},{"Id":410014,"FormularyType":"OHP","DrugName":"WARFARIN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"65162076810"},{"Id":410015,"FormularyType":"OHP","DrugName":"WARFARIN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"65162076811"},{"Id":410016,"FormularyType":"OHP","DrugName":"WARFARIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"65162076910"},{"Id":410017,"FormularyType":"OHP","DrugName":"WARFARIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"65162076911"},{"Id":410018,"FormularyType":"OHP","DrugName":"BUDESONIDE CAP 3MG DR","DosageForm":"CPEP - Capsule DR Part","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100012006720","GenericName":"BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","NDC":"65162077810"},{"Id":410019,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"65162080114"},{"Id":410020,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"65162080151"},{"Id":410021,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"65162080214"},{"Id":410022,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"65162080251"},{"Id":410023,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"65162080314"},{"Id":410024,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"65162080351"},{"Id":410025,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"65162080414"},{"Id":410026,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"65162080451"},{"Id":410027,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"65162080514"},{"Id":410028,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"65162080551"},{"Id":410029,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"65162080651"},{"Id":410030,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"65162080710"},{"Id":410031,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"65162080810"},{"Id":410032,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"65162083703"},{"Id":410033,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"65162083809"},{"Id":410034,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"65162083909"},{"Id":410035,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"65162084009"},{"Id":410036,"FormularyType":"OHP","DrugName":"VORICONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407080001920","GenericName":"VORICONAZOLE FOR SUSP 40 MG/ML","NDC":"65162091322"},{"Id":410037,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"65162091446"},{"Id":410038,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"65162098904"},{"Id":410039,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"65162098908"},{"Id":410040,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"65162099204"},{"Id":410041,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"65162099208"},{"Id":410042,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"65162099304"},{"Id":410043,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"65162099308"},{"Id":410044,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"65162099504"},{"Id":410045,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"65162099508"},{"Id":410046,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"65162099704"},{"Id":410047,"FormularyType":"OHP","DrugName":"DOTTI DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"65162099708"},{"Id":410048,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002055","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/50ML","NDC":"65219000400"},{"Id":410049,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002055","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/50ML","NDC":"65219000401"},{"Id":410050,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002060","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/100ML","NDC":"65219000600"},{"Id":410051,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002060","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/100ML","NDC":"65219000601"},{"Id":410052,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002070","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/50ML","NDC":"65219000850"},{"Id":410053,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 20MEQ","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002070","GenericName":"POTASSIUM CHLORIDE INJ 20 MEQ/50ML","NDC":"65219000851"},{"Id":410054,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 40MEQ","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002075","GenericName":"POTASSIUM CHLORIDE INJ 40 MEQ/100ML","NDC":"65219001000"},{"Id":410055,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 40MEQ","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002075","GenericName":"POTASSIUM CHLORIDE INJ 40 MEQ/100ML","NDC":"65219001001"},{"Id":410056,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002050","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/100ML","NDC":"65219001200"},{"Id":410057,"FormularyType":"OHP","DrugName":"POT CHLORIDE INJ 10MEQ","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002050","GenericName":"POTASSIUM CHLORIDE INJ 10 MEQ/100ML","NDC":"65219001201"},{"Id":410058,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302110","GenericName":"AMPICILLIN SODIUM FOR INJ 250 MG","NDC":"65219001401"},{"Id":410059,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 250MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302110","GenericName":"AMPICILLIN SODIUM FOR INJ 250 MG","NDC":"65219001410"},{"Id":410060,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"65219001601"},{"Id":410061,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"65219001610"},{"Id":410062,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"65219001801"},{"Id":410063,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"65219001810"},{"Id":410064,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"65219002003"},{"Id":410065,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"65219002023"},{"Id":410066,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/10","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"65219006601"},{"Id":410067,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/10","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"65219006610"},{"Id":410068,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"65219018701"},{"Id":410069,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"65219018710"},{"Id":410070,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"65219020401"},{"Id":410071,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"65219020420"},{"Id":410072,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219021801"},{"Id":410073,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219021850"},{"Id":410074,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219022001"},{"Id":410075,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219022010"},{"Id":410076,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219022201"},{"Id":410077,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219022225"},{"Id":410078,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219022401"},{"Id":410079,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219022450"},{"Id":410080,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219022601"},{"Id":410081,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219022650"},{"Id":410082,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219022801"},{"Id":410083,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219022810"},{"Id":410084,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219023001"},{"Id":410085,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219023025"},{"Id":410086,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219023201"},{"Id":410087,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.45%","DosageForm":"SOLN - Solution","Strength":"0.45","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002010","GenericName":"SODIUM CHLORIDE IV SOLN 0.45%","NDC":"65219023250"},{"Id":410088,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219023401"},{"Id":410089,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219023410"},{"Id":410090,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219023601"},{"Id":410091,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219023610"},{"Id":410092,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219023801"},{"Id":410093,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219023825"},{"Id":410094,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219024001"},{"Id":410095,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219024050"},{"Id":410096,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"65219025600"},{"Id":410097,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"65219025624"},{"Id":410098,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 36-4.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"65219025628"},{"Id":410099,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"65219025905"},{"Id":410100,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"65219025915"},{"Id":410101,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"65219025945"},{"Id":410102,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"65219025955"},{"Id":410103,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"65219029300"},{"Id":410104,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"65219029301"},{"Id":410105,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 40/10ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"65219029510"},{"Id":410106,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"65219036801"},{"Id":410107,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"65219036802"},{"Id":410108,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"65219038401"},{"Id":410109,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"65219038402"},{"Id":410110,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"65219043402"},{"Id":410111,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"65219043420"},{"Id":410112,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"65219043602"},{"Id":410113,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"65219043620"},{"Id":410114,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219045605"},{"Id":410115,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219045660"},{"Id":410116,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219045805"},{"Id":410117,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219045830"},{"Id":410118,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219046005"},{"Id":410119,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219046020"},{"Id":410120,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219046205"},{"Id":410121,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219046210"},{"Id":410122,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219046405"},{"Id":410123,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 5%","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002015","GenericName":"DEXTROSE INJ 5%","NDC":"65219046450"},{"Id":410124,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219046605"},{"Id":410125,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219046660"},{"Id":410126,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219046805"},{"Id":410127,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219046850"},{"Id":410128,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219047005"},{"Id":410129,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219047030"},{"Id":410130,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219047205"},{"Id":410131,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219047220"},{"Id":410132,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219047405"},{"Id":410133,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"65219047410"},{"Id":410134,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"65219049903"},{"Id":410135,"FormularyType":"OHP","DrugName":"STERIL WATER SOL IRRIG","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IRRIGATION SOLUTIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99750005002000","GenericName":"WATER FOR IRRIGATION, STERILE IRRIGATION SOLN","NDC":"65219049930"},{"Id":410136,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"65219050603"},{"Id":410137,"FormularyType":"OHP","DrugName":"SODIUM CHLOR SOL 0.9% IRR","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"GENITOURINARY IRRIGANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56700060002010","GenericName":"SODIUM CHLORIDE IRRIGATION SOLN 0.9%","NDC":"65219050630"},{"Id":410138,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"65219051002"},{"Id":410139,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"65219051020"},{"Id":410140,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"65219051202"},{"Id":410141,"FormularyType":"OHP","DrugName":"POT ACETATE INJ 2MEQ/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700010002020","GenericName":"POTASSIUM ACETATE INJ 2 MEQ/ML","NDC":"65219051250"},{"Id":410142,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"65219057001"},{"Id":410143,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"65219057004"},{"Id":410144,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"65219057201"},{"Id":410145,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"65219057210"},{"Id":410146,"FormularyType":"OHP","DrugName":"TYENNE INJ 162/0.9","DosageForm":"SOAJ - Soln Auto-inj","Strength":"162","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"INTERLEUKIN-6 RECEPTOR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6650007017D520","GenericName":"TOCILIZUMAB-AAZG SUBCUTANEOUS SOLN AUTO-INJ 162 MG/0.9ML","NDC":"65219059601"},{"Id":410147,"FormularyType":"OHP","DrugName":"TYENNE INJ 162MG","DosageForm":"SOSY - Soln Pref Syr","Strength":"162","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"INTERLEUKIN-6 RECEPTOR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6650007017E520","GenericName":"TOCILIZUMAB-AAZG SUBCUTANEOUS SOLN PREF SYR 162 MG/0.9ML","NDC":"65219059810"},{"Id":410148,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504000492"},{"Id":410149,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504000495"},{"Id":410150,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504000497"},{"Id":410151,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504000692"},{"Id":410152,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504000695"},{"Id":410153,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"65504001515"},{"Id":410154,"FormularyType":"OHP","DrugName":"TOTAL ALLERG LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"65504003607"},{"Id":410155,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"65504004695"},{"Id":410156,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"65504007495"},{"Id":410157,"FormularyType":"OHP","DrugName":"ASPIRIN CHLD CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"65504010308"},{"Id":410158,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"65504010405"},{"Id":410159,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"65504010505"},{"Id":410160,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"65504010605"},{"Id":410161,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"65504010705"},{"Id":410162,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504010905"},{"Id":410163,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504011005"},{"Id":410164,"FormularyType":"OHP","DrugName":"SENNA-LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"65504019095"},{"Id":410165,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"65504020002"},{"Id":410166,"FormularyType":"OHP","DrugName":"TOTAL ALLERG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"65504020902"},{"Id":410167,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"65504023095"},{"Id":410168,"FormularyType":"OHP","DrugName":"CHLD NON-ASA CHW 80MG GRP","DosageForm":"CHEW - Tablet Chewable","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000505","GenericName":"ACETAMINOPHEN CHEW TAB 80 MG","NDC":"65504027289"},{"Id":410169,"FormularyType":"OHP","DrugName":"NON-ASPIRIN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"65504028007"},{"Id":410170,"FormularyType":"OHP","DrugName":"ANTACID FAST SUS RELIEF","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"65504030016"},{"Id":410171,"FormularyType":"OHP","DrugName":"ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"65504030116"},{"Id":410172,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 400/5ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"65504030416"},{"Id":410173,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"65504030903"},{"Id":410174,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"65504031111"},{"Id":410175,"FormularyType":"OHP","DrugName":"FIBER TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"65504031209"},{"Id":410176,"FormularyType":"OHP","DrugName":"WOMENS LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"65504031503"},{"Id":410177,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"65504031621"},{"Id":410178,"FormularyType":"OHP","DrugName":"DSS CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"65504090005"},{"Id":410179,"FormularyType":"OHP","DrugName":"DSS CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"65504090105"},{"Id":410180,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"65504090209"},{"Id":410181,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504090405"},{"Id":410182,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"65504090452"},{"Id":410183,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"65504090603"},{"Id":410184,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"65504090911"},{"Id":410185,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"65504091011"},{"Id":410186,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"65504091307"},{"Id":410187,"FormularyType":"OHP","DrugName":"AFTERPILL TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"65542000000"},{"Id":410188,"FormularyType":"OHP","DrugName":"TURALIO CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533045010110","GenericName":"PEXIDARTINIB HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"65597040720"},{"Id":410189,"FormularyType":"OHP","DrugName":"TURALIO CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533045010110","GenericName":"PEXIDARTINIB HCL CAP 125 MG (BASE EQUIVALENT)","NDC":"65597040728"},{"Id":410190,"FormularyType":"OHP","DrugName":"VANFLYTA TAB 17.7MG","DosageForm":"TABS - Tablet","Strength":"17.7","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533047100320","GenericName":"QUIZARTINIB DIHYDROCHLORIDE TAB 17.7 MG","NDC":"65597050404"},{"Id":410191,"FormularyType":"OHP","DrugName":"VANFLYTA TAB 17.7MG","DosageForm":"TABS - Tablet","Strength":"17.7","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533047100320","GenericName":"QUIZARTINIB DIHYDROCHLORIDE TAB 17.7 MG","NDC":"65597050428"},{"Id":410192,"FormularyType":"OHP","DrugName":"VANFLYTA TAB 26.5MG","DosageForm":"TABS - Tablet","Strength":"26.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533047100325","GenericName":"QUIZARTINIB DIHYDROCHLORIDE TAB 26.5 MG","NDC":"65597051104"},{"Id":410193,"FormularyType":"OHP","DrugName":"VANFLYTA TAB 26.5MG","DosageForm":"TABS - Tablet","Strength":"26.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533047100325","GenericName":"QUIZARTINIB DIHYDROCHLORIDE TAB 26.5 MG","NDC":"65597051128"},{"Id":410194,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE SUS 3MG/ML","DosageForm":"SUSP - Suspension","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49270040001820","GenericName":"*LANSOPRAZOLE SUSP 3 MG/ML (COMPOUND KIT)**","NDC":"65628008003"},{"Id":410195,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE SUS 3MG/ML","DosageForm":"SUSP - Suspension","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49270040001820","GenericName":"*LANSOPRAZOLE SUSP 3 MG/ML (COMPOUND KIT)**","NDC":"65628008005"},{"Id":410196,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE SUS 3MG/ML","DosageForm":"SUSP - Suspension","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49270040001820","GenericName":"*LANSOPRAZOLE SUSP 3 MG/ML (COMPOUND KIT)**","NDC":"65628008010"},{"Id":410197,"FormularyType":"OHP","DrugName":"XIFAXAN TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000049000340","GenericName":"RIFAXIMIN TAB 550 MG","NDC":"65649030301"},{"Id":410198,"FormularyType":"OHP","DrugName":"XIFAXAN TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000049000340","GenericName":"RIFAXIMIN TAB 550 MG","NDC":"65649030302"},{"Id":410199,"FormularyType":"OHP","DrugName":"XIFAXAN TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000049000340","GenericName":"RIFAXIMIN TAB 550 MG","NDC":"65649030303"},{"Id":410200,"FormularyType":"OHP","DrugName":"XIFAXAN TAB 550MG","DosageForm":"TABS - Tablet","Strength":"550","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000049000340","GenericName":"RIFAXIMIN TAB 550 MG","NDC":"65649030305"},{"Id":410201,"FormularyType":"OHP","DrugName":"VIVITROL INJ 380MG","DosageForm":"SUSR - Suspension Reconstituted","Strength":"380","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030001920","GenericName":"NALTREXONE FOR IM EXTENDED RELEASE SUSP 380 MG","NDC":"65757030001"},{"Id":410202,"FormularyType":"OHP","DrugName":"PEAK FLW MTR MIS UNIVERSL","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"65845001801"},{"Id":410203,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"65862000801"},{"Id":410204,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"65862000805"},{"Id":410205,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"65862000899"},{"Id":410206,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"65862000901"},{"Id":410207,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"65862000905"},{"Id":410208,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"65862001001"},{"Id":410209,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"65862001005"},{"Id":410210,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"65862001046"},{"Id":410211,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"65862001099"},{"Id":410212,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100303","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 500 MG","NDC":"65862001401"},{"Id":410213,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100303","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 500 MG","NDC":"65862001405"},{"Id":410214,"FormularyType":"OHP","DrugName":"AMOXICILLIN TAB 875MG","DosageForm":"TABS - Tablet","Strength":"875","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100315","GenericName":"AMOXICILLIN (TRIHYDRATE) TAB 875 MG","NDC":"65862001501"},{"Id":410215,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"65862001601"},{"Id":410216,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100105","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 250 MG","NDC":"65862001605"},{"Id":410217,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"65862001701"},{"Id":410218,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"65862001705"},{"Id":410219,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"65862001801"},{"Id":410220,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"65862001805"},{"Id":410221,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"65862001840"},{"Id":410222,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"65862001901"},{"Id":410223,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"65862001905"},{"Id":410224,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"65862001940"},{"Id":410225,"FormularyType":"OHP","DrugName":"ZIDOVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108085000330","GenericName":"ZIDOVUDINE TAB 300 MG","NDC":"65862002460"},{"Id":410226,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000320","GenericName":"LAMIVUDINE TAB 150 MG","NDC":"65862002560"},{"Id":410227,"FormularyType":"OHP","DrugName":"LAMIVUDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060000330","GenericName":"LAMIVUDINE TAB 300 MG","NDC":"65862002630"},{"Id":410228,"FormularyType":"OHP","DrugName":"NEVIRAPINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050000320","GenericName":"NEVIRAPINE TAB 200 MG","NDC":"65862002760"},{"Id":410229,"FormularyType":"OHP","DrugName":"LAMIVUD/ZIDO TAB 150-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902500320","GenericName":"LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG","NDC":"65862003660"},{"Id":410230,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"65862003701"},{"Id":410231,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"65862003705"},{"Id":410232,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"65862003799"},{"Id":410233,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"65862003801"},{"Id":410234,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"65862003805"},{"Id":410235,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"65862003899"},{"Id":410236,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"65862003901"},{"Id":410237,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"65862003905"},{"Id":410238,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"65862003999"},{"Id":410239,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"65862004001"},{"Id":410240,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"65862004005"},{"Id":410241,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"65862004099"},{"Id":410242,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"65862004101"},{"Id":410243,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"65862004105"},{"Id":410244,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"65862004199"},{"Id":410245,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"65862004201"},{"Id":410246,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"65862004205"},{"Id":410247,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"65862004299"},{"Id":410248,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"65862004301"},{"Id":410249,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"65862004305"},{"Id":410250,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"65862004401"},{"Id":410251,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"65862004405"},{"Id":410252,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"65862004501"},{"Id":410253,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"65862004505"},{"Id":410254,"FormularyType":"OHP","DrugName":"ZIDOVUDINE SYP 50MG/5ML","DosageForm":"SYRP - Syrup","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108085001210","GenericName":"ZIDOVUDINE SYRUP 10 MG/ML","NDC":"65862004824"},{"Id":410255,"FormularyType":"OHP","DrugName":"EFAVIRENZ TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109030000330","GenericName":"EFAVIRENZ TAB 600 MG","NDC":"65862004930"},{"Id":410256,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"65862005030"},{"Id":410257,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"65862005090"},{"Id":410258,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"65862005126"},{"Id":410259,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"65862005130"},{"Id":410260,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"65862005190"},{"Id":410261,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"65862005199"},{"Id":410262,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"65862005226"},{"Id":410263,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"65862005230"},{"Id":410264,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"65862005290"},{"Id":410265,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"65862005299"},{"Id":410266,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"65862005322"},{"Id":410267,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"65862005330"},{"Id":410268,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"65862005390"},{"Id":410269,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"65862005399"},{"Id":410270,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"65862005430"},{"Id":410271,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"65862005439"},{"Id":410272,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"65862005490"},{"Id":410273,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"65862005499"},{"Id":410274,"FormularyType":"OHP","DrugName":"LAMIVUDINE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060002020","GenericName":"LAMIVUDINE ORAL SOLN 10 MG/ML","NDC":"65862005524"},{"Id":410275,"FormularyType":"OHP","DrugName":"NEVIRAPINE SUS 50MG/5ML","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109050001820","GenericName":"NEVIRAPINE SUSP 50 MG/5ML","NDC":"65862005724"},{"Id":410276,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"65862006201"},{"Id":410277,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"65862006299"},{"Id":410278,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"65862006301"},{"Id":410279,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"65862006359"},{"Id":410280,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"65862006399"},{"Id":410281,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"65862006401"},{"Id":410282,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"65862006439"},{"Id":410283,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"65862006499"},{"Id":410284,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"65862006801"},{"Id":410285,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"65862006901"},{"Id":410286,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"65862006950"},{"Id":410287,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"65862007001"},{"Id":410288,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"65862007050"},{"Id":410289,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101913","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","NDC":"65862007075"},{"Id":410290,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"65862007101"},{"Id":410291,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"65862007150"},{"Id":410292,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"65862007175"},{"Id":410293,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"65862007360"},{"Id":410294,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"65862007601"},{"Id":410295,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"65862007701"},{"Id":410296,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"65862007705"},{"Id":410297,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"65862007850"},{"Id":410298,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"65862007930"},{"Id":410299,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 1.25-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400310","GenericName":"GLYBURIDE-METFORMIN TAB 1.25-250 MG","NDC":"65862008001"},{"Id":410300,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 1.25-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400310","GenericName":"GLYBURIDE-METFORMIN TAB 1.25-250 MG","NDC":"65862008005"},{"Id":410301,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400320","GenericName":"GLYBURIDE-METFORMIN TAB 2.5-500 MG","NDC":"65862008101"},{"Id":410302,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 2.5-500","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400320","GenericName":"GLYBURIDE-METFORMIN TAB 2.5-500 MG","NDC":"65862008105"},{"Id":410303,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400330","GenericName":"GLYBURIDE-METFORMIN TAB 5-500 MG","NDC":"65862008201"},{"Id":410304,"FormularyType":"OHP","DrugName":"GLYB/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002400330","GenericName":"GLYBURIDE-METFORMIN TAB 5-500 MG","NDC":"65862008205"},{"Id":410305,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001910","GenericName":"CEFADROXIL FOR SUSP 250 MG/5ML","NDC":"65862008301"},{"Id":410306,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"65862008401"},{"Id":410307,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"65862008475"},{"Id":410308,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"65862008501"},{"Id":410309,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"65862008550"},{"Id":410310,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"65862008601"},{"Id":410311,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"65862008630"},{"Id":410312,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"65862008701"},{"Id":410313,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"65862008730"},{"Id":410314,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100320","GenericName":"CEFPODOXIME PROXETIL TAB 100 MG","NDC":"65862009501"},{"Id":410315,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100320","GenericName":"CEFPODOXIME PROXETIL TAB 100 MG","NDC":"65862009520"},{"Id":410316,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100330","GenericName":"CEFPODOXIME PROXETIL TAB 200 MG","NDC":"65862009601"},{"Id":410317,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100330","GenericName":"CEFPODOXIME PROXETIL TAB 200 MG","NDC":"65862009620"},{"Id":410318,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"65862009701"},{"Id":410319,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"65862009705"},{"Id":410320,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"65862009801"},{"Id":410321,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"65862009805"},{"Id":410322,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"65862009901"},{"Id":410323,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"65862009975"},{"Id":410324,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"65862010001"},{"Id":410325,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"65862010075"},{"Id":410326,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"65862010190"},{"Id":410327,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"65862010199"},{"Id":410328,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"65862010205"},{"Id":410329,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"65862010290"},{"Id":410330,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"65862010305"},{"Id":410331,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"65862010390"},{"Id":410332,"FormularyType":"OHP","DrugName":"ZIDOVUDINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108085000110","GenericName":"ZIDOVUDINE CAP 100 MG","NDC":"65862010701"},{"Id":410333,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"65862011301"},{"Id":410334,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"65862011399"},{"Id":410335,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100330","GenericName":"BENAZEPRIL HCL TAB 20 MG","NDC":"65862011701"},{"Id":410336,"FormularyType":"OHP","DrugName":"BENAZEPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100005100340","GenericName":"BENAZEPRIL HCL TAB 40 MG","NDC":"65862011801"},{"Id":410337,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"65862012501"},{"Id":410338,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"65862012601"},{"Id":410339,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"65862012701"},{"Id":410340,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"65862012801"},{"Id":410341,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"65862013301"},{"Id":410342,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"65862013399"},{"Id":410343,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"65862013401"},{"Id":410344,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"65862013499"},{"Id":410345,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 50MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"50","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101920","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML","NDC":"65862014001"},{"Id":410346,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 50MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"50","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101920","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML","NDC":"65862014050"},{"Id":410347,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101930","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","NDC":"65862014101"},{"Id":410348,"FormularyType":"OHP","DrugName":"CEFPODO PROX SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"M","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065101930","GenericName":"CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","NDC":"65862014150"},{"Id":410349,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"65862014201"},{"Id":410350,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"65862014205"},{"Id":410351,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"65862014301"},{"Id":410352,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"65862014305"},{"Id":410353,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"65862014401"},{"Id":410354,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"65862014405"},{"Id":410355,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"65862014501"},{"Id":410356,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"65862014505"},{"Id":410357,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"65862014636"},{"Id":410358,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"65862014736"},{"Id":410359,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"65862014836"},{"Id":410360,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"65862014901"},{"Id":410361,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"65862014905"},{"Id":410362,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"65862014930"},{"Id":410363,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"65862014990"},{"Id":410364,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"65862015901"},{"Id":410365,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"65862015905"},{"Id":410366,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"65862015999"},{"Id":410367,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"65862016001"},{"Id":410368,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"65862016005"},{"Id":410369,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"65862016099"},{"Id":410370,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"65862016801"},{"Id":410371,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"65862016899"},{"Id":410372,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"65862016901"},{"Id":410373,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"65862016999"},{"Id":410374,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"65862017001"},{"Id":410375,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"65862017099"},{"Id":410376,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"65862017160"},{"Id":410377,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"65862017260"},{"Id":410378,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"65862017360"},{"Id":410379,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"65862017460"},{"Id":410380,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"65862017501"},{"Id":410381,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100310","GenericName":"PENICILLIN V POTASSIUM TAB 250 MG","NDC":"65862017599"},{"Id":410382,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"65862017601"},{"Id":410383,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"65862017605"},{"Id":410384,"FormularyType":"OHP","DrugName":"PENICILLN VK TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100040100315","GenericName":"PENICILLIN V POTASSIUM TAB 500 MG","NDC":"65862017699"},{"Id":410385,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"65862017760"},{"Id":410386,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"65862018501"},{"Id":410387,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"65862018505"},{"Id":410388,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"65862018601"},{"Id":410389,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"65862018730"},{"Id":410390,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"65862018830"},{"Id":410391,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"65862019001"},{"Id":410392,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"65862019101"},{"Id":410393,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"65862019105"},{"Id":410394,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"65862019199"},{"Id":410395,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"65862019801"},{"Id":410396,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"65862019805"},{"Id":410397,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"65862019899"},{"Id":410398,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"65862019901"},{"Id":410399,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"65862019905"},{"Id":410400,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"65862019999"},{"Id":410401,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"65862020001"},{"Id":410402,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"65862020005"},{"Id":410403,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"65862020190"},{"Id":410404,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"65862020199"},{"Id":410405,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"65862020230"},{"Id":410406,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"65862020290"},{"Id":410407,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"65862020299"},{"Id":410408,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"65862020330"},{"Id":410409,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"65862020390"},{"Id":410410,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"65862020399"},{"Id":410411,"FormularyType":"OHP","DrugName":"RIBAVIRIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12353070000320","GenericName":"RIBAVIRIN TAB 200 MG","NDC":"65862020768"},{"Id":410412,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"65862020901"},{"Id":410413,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"65862021105"},{"Id":410414,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"65862021150"},{"Id":410415,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000120","GenericName":"ZALEPLON CAP 5 MG","NDC":"65862021401"},{"Id":410416,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000130","GenericName":"ZALEPLON CAP 10 MG","NDC":"65862021501"},{"Id":410417,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"65862021801"},{"Id":410418,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"65862021860"},{"Id":410419,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"65862021901"},{"Id":410420,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"65862021960"},{"Id":410421,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000310","GenericName":"CLARITHROMYCIN TAB 250 MG","NDC":"65862022560"},{"Id":410422,"FormularyType":"OHP","DrugName":"CLARITHROMYC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"CLARITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03500010000320","GenericName":"CLARITHROMYCIN TAB 500 MG","NDC":"65862022660"},{"Id":410423,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"65862023703"},{"Id":410424,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"65862024505"},{"Id":410425,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"65862024508"},{"Id":410426,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"65862024605"},{"Id":410427,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"65862024608"},{"Id":410428,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"65862024705"},{"Id":410429,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"65862024708"},{"Id":410430,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"65862024901"},{"Id":410431,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"65862025047"},{"Id":410432,"FormularyType":"OHP","DrugName":"RIBAVIRIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12353070000120","GenericName":"RIBAVIRIN CAP 200 MG","NDC":"65862029018"},{"Id":410433,"FormularyType":"OHP","DrugName":"RIBAVIRIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12353070000120","GenericName":"RIBAVIRIN CAP 200 MG","NDC":"65862029042"},{"Id":410434,"FormularyType":"OHP","DrugName":"RIBAVIRIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12353070000120","GenericName":"RIBAVIRIN CAP 200 MG","NDC":"65862029056"},{"Id":410435,"FormularyType":"OHP","DrugName":"RIBAVIRIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12353070000120","GenericName":"RIBAVIRIN CAP 200 MG","NDC":"65862029070"},{"Id":410436,"FormularyType":"OHP","DrugName":"RIBAVIRIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12353070000120","GenericName":"RIBAVIRIN CAP 200 MG","NDC":"65862029084"},{"Id":410437,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"65862029390"},{"Id":410438,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"65862029399"},{"Id":410439,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"65862029490"},{"Id":410440,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"65862029499"},{"Id":410441,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"65862029590"},{"Id":410442,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"65862029599"},{"Id":410443,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"65862029630"},{"Id":410444,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"65862029690"},{"Id":410445,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"65862029699"},{"Id":410446,"FormularyType":"OHP","DrugName":"EMTRICITABIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106030000120","GenericName":"EMTRICITABINE CAPS 200 MG","NDC":"65862030130"},{"Id":410447,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"65862031560"},{"Id":410448,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"65862032530"},{"Id":410449,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"65862032590"},{"Id":410450,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"65862032599"},{"Id":410451,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"65862032630"},{"Id":410452,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"65862032690"},{"Id":410453,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"65862032699"},{"Id":410454,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100310","GenericName":"ALENDRONATE SODIUM TAB 10 MG","NDC":"65862032730"},{"Id":410455,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"65862032804"},{"Id":410456,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"65862032904"},{"Id":410457,"FormularyType":"OHP","DrugName":"ABACA/LAMIVU TAB 600-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902200340","GenericName":"ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG","NDC":"65862033530"},{"Id":410458,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"65862035430"},{"Id":410459,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"65862035701"},{"Id":410460,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"65862035705"},{"Id":410461,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"65862035730"},{"Id":410462,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"65862035761"},{"Id":410463,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"65862035790"},{"Id":410464,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"65862039010"},{"Id":410465,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"65862039110"},{"Id":410466,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"65862041901"},{"Id":410467,"FormularyType":"OHP","DrugName":"SMZ-TMP TAB 400-80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300310","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","NDC":"65862041905"},{"Id":410468,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"65862042001"},{"Id":410469,"FormularyType":"OHP","DrugName":"SMZ/TMP DS TAB 800-160","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002300320","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","NDC":"65862042005"},{"Id":410470,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"65862042130"},{"Id":410471,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"65862044830"},{"Id":410472,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"65862044890"},{"Id":410473,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"65862044930"},{"Id":410474,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"65862044990"},{"Id":410475,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100320","GenericName":"GALANTAMINE HYDROBROMIDE TAB 4 MG","NDC":"65862045860"},{"Id":410476,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100330","GenericName":"GALANTAMINE HYDROBROMIDE TAB 8 MG","NDC":"65862045960"},{"Id":410477,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100340","GenericName":"GALANTAMINE HYDROBROMIDE TAB 12 MG","NDC":"65862046060"},{"Id":410478,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000305","GenericName":"FAMCICLOVIR TAB 125 MG","NDC":"65862046530"},{"Id":410479,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000310","GenericName":"FAMCICLOVIR TAB 250 MG","NDC":"65862046630"},{"Id":410480,"FormularyType":"OHP","DrugName":"FAMCICLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12408040000320","GenericName":"FAMCICLOVIR TAB 500 MG","NDC":"65862046730"},{"Id":410481,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"65862046830"},{"Id":410482,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"65862046890"},{"Id":410483,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"65862046899"},{"Id":410484,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"65862046930"},{"Id":410485,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"65862046990"},{"Id":410486,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"65862046999"},{"Id":410487,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"65862047030"},{"Id":410488,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"65862047090"},{"Id":410489,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"65862047099"},{"Id":410490,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"65862047190"},{"Id":410491,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"65862047290"},{"Id":410492,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"65862047390"},{"Id":410493,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"65862047401"},{"Id":410494,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"65862047430"},{"Id":410495,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"65862047501"},{"Id":410496,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"65862047505"},{"Id":410497,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"65862047601"},{"Id":410498,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"65862047605"},{"Id":410499,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"65862047701"},{"Id":410500,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"65862047705"},{"Id":410501,"FormularyType":"OHP","DrugName":"SMZ-TMP SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"65862049647"},{"Id":410502,"FormularyType":"OHP","DrugName":"EFAVIR/EMTRI TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903300320","GenericName":"EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG","NDC":"65862049730"},{"Id":410503,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 250-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200310","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 250-125 MG","NDC":"65862050130"},{"Id":410504,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 500-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200320","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","NDC":"65862050220"},{"Id":410505,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"65862050301"},{"Id":410506,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"65862050320"},{"Id":410507,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"65862051205"},{"Id":410508,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"65862051230"},{"Id":410509,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"65862051290"},{"Id":410510,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"65862051305"},{"Id":410511,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"65862051330"},{"Id":410512,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"65862051405"},{"Id":410513,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"65862051430"},{"Id":410514,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"65862051490"},{"Id":410515,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100305","GenericName":"RISEDRONATE SODIUM TAB 5 MG","NDC":"65862051730"},{"Id":410516,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"65862051904"},{"Id":410517,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100330","GenericName":"RISEDRONATE SODIUM TAB 35 MG","NDC":"65862051908"},{"Id":410518,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"65862052001"},{"Id":410519,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"65862052005"},{"Id":410520,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"65862052099"},{"Id":410521,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"65862052101"},{"Id":410522,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"65862052105"},{"Id":410523,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"65862052199"},{"Id":410524,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"65862052201"},{"Id":410525,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"65862052205"},{"Id":410526,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"65862052301"},{"Id":410527,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"65862052305"},{"Id":410528,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"65862052401"},{"Id":410529,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"65862052405"},{"Id":410530,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400320","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","NDC":"65862052518"},{"Id":410531,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400320","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","NDC":"65862052560"},{"Id":410532,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-850MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400340","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","NDC":"65862052618"},{"Id":410533,"FormularyType":"OHP","DrugName":"PIOGLITA/MET TAB 15-850MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27998002400340","GenericName":"PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","NDC":"65862052660"},{"Id":410534,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"65862053301"},{"Id":410535,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"65862053350"},{"Id":410536,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201915","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","NDC":"65862053375"},{"Id":410537,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"65862053401"},{"Id":410538,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"65862053450"},{"Id":410539,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"65862053475"},{"Id":410540,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"65862053502"},{"Id":410541,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"65862053513"},{"Id":410542,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"65862053575"},{"Id":410543,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"65862053650"},{"Id":410544,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"65862053750"},{"Id":410545,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"65862053820"},{"Id":410546,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"65862054790"},{"Id":410547,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 80-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700320","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","NDC":"65862054799"},{"Id":410548,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"65862054890"},{"Id":410549,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700340","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","NDC":"65862054899"},{"Id":410550,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"65862054990"},{"Id":410551,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 160-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700350","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","NDC":"65862054999"},{"Id":410552,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"65862055005"},{"Id":410553,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700360","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","NDC":"65862055090"},{"Id":410554,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"65862055105"},{"Id":410555,"FormularyType":"OHP","DrugName":"VALSART/HCTZ TAB 320-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002700370","GenericName":"VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","NDC":"65862055190"},{"Id":410556,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"65862055990"},{"Id":410557,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"65862055999"},{"Id":410558,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"65862056090"},{"Id":410559,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"65862056099"},{"Id":410560,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 4MG","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100516","GenericName":"MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","NDC":"65862056790"},{"Id":410561,"FormularyType":"OHP","DrugName":"MONTELUKAST CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100520","GenericName":"MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","NDC":"65862056890"},{"Id":410562,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"65862057030"},{"Id":410563,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"65862057190"},{"Id":410564,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"65862057290"},{"Id":410565,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"65862057390"},{"Id":410566,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"65862057490"},{"Id":410567,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 2.5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200120","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","NDC":"65862058201"},{"Id":410568,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"65862058301"},{"Id":410569,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"65862058305"},{"Id":410570,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"65862058401"},{"Id":410571,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"65862058405"},{"Id":410572,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200145","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","NDC":"65862058501"},{"Id":410573,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200145","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","NDC":"65862058505"},{"Id":410574,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"65862058601"},{"Id":410575,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"65862058605"},{"Id":410576,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"65862058701"},{"Id":410577,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"65862058705"},{"Id":410578,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"65862059601"},{"Id":410579,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 75MG/5ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"16220020222120","GenericName":"CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","NDC":"65862059602"},{"Id":410580,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"65862059801"},{"Id":410581,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"65862059805"},{"Id":410582,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"65862059903"},{"Id":410583,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"65862059912"},{"Id":410584,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"65862060003"},{"Id":410585,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"65862060012"},{"Id":410586,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"65862060330"},{"Id":410587,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"65862060490"},{"Id":410588,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"65862060499"},{"Id":410589,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"65862060590"},{"Id":410590,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"65862060599"},{"Id":410591,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"65862060690"},{"Id":410592,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"65862060699"},{"Id":410593,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"65862060790"},{"Id":410594,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100317","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","NDC":"65862060799"},{"Id":410595,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"65862060890"},{"Id":410596,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"65862060899"},{"Id":410597,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"65862060990"},{"Id":410598,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"65862060999"},{"Id":410599,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"65862062101"},{"Id":410600,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"65862062201"},{"Id":410601,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"65862062301"},{"Id":410602,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"65862062405"},{"Id":410603,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"65862062460"},{"Id":410604,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"65862062503"},{"Id":410605,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"65862062512"},{"Id":410606,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"65862062590"},{"Id":410607,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"65862062603"},{"Id":410608,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"65862062612"},{"Id":410609,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"65862062690"},{"Id":410610,"FormularyType":"OHP","DrugName":"IRBESAR/HCTZ TAB 300-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002300340","GenericName":"IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","NDC":"65862063030"},{"Id":410611,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"65862063730"},{"Id":410612,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"65862063790"},{"Id":410613,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"65862063805"},{"Id":410614,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"65862063830"},{"Id":410615,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"65862063890"},{"Id":410616,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"65862063905"},{"Id":410617,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"65862063930"},{"Id":410618,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"65862063990"},{"Id":410619,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"65862064130"},{"Id":410620,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"65862064163"},{"Id":410621,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"65862064169"},{"Id":410622,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"65862064230"},{"Id":410623,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"65862064264"},{"Id":410624,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"65862064290"},{"Id":410625,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"65862064860"},{"Id":410626,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"65862064960"},{"Id":410627,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"65862065060"},{"Id":410628,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"65862065160"},{"Id":410629,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"65862065260"},{"Id":410630,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"65862065360"},{"Id":410631,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"65862065399"},{"Id":410632,"FormularyType":"OHP","DrugName":"ENTACAPONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON COMT INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73153030000320","GenericName":"ENTACAPONE TAB 200 MG","NDC":"65862065401"},{"Id":410633,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"65862067301"},{"Id":410634,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"65862067399"},{"Id":410635,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"65862067401"},{"Id":410636,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"65862067499"},{"Id":410637,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"65862067599"},{"Id":410638,"FormularyType":"OHP","DrugName":"RITONAVIR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104560000320","GenericName":"RITONAVIR TAB 100 MG","NDC":"65862068730"},{"Id":410639,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"65862068890"},{"Id":410640,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"65862068899"},{"Id":410641,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"65862069201"},{"Id":410642,"FormularyType":"OHP","DrugName":"PHENYTOIN EX CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030200110","GenericName":"PHENYTOIN SODIUM EXTENDED CAP 100 MG","NDC":"65862069299"},{"Id":410643,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"65862069401"},{"Id":410644,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"65862069405"},{"Id":410645,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"65862069425"},{"Id":410646,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"65862069501"},{"Id":410647,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"65862069505"},{"Id":410648,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"65862069550"},{"Id":410649,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"65862069920"},{"Id":410650,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"65862069960"},{"Id":410651,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"65862070020"},{"Id":410652,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"65862070060"},{"Id":410653,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"65862070601"},{"Id":410654,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"65862070655"},{"Id":410655,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101910","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","NDC":"65862070680"},{"Id":410656,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"65862070701"},{"Id":410657,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"65862070755"},{"Id":410658,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101915","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","NDC":"65862070780"},{"Id":410659,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"65862070901"},{"Id":410660,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"65862070930"},{"Id":410661,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200130","GenericName":"ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV)","NDC":"65862071160"},{"Id":410662,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200140","GenericName":"ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV)","NDC":"65862071260"},{"Id":410663,"FormularyType":"OHP","DrugName":"ATAZANAVIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104515200150","GenericName":"ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV)","NDC":"65862071330"},{"Id":410664,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"65862072130"},{"Id":410665,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"65862072190"},{"Id":410666,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"65862073205"},{"Id":410667,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"65862073260"},{"Id":410668,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"65862074130"},{"Id":410669,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"65862074230"},{"Id":410670,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"65862074290"},{"Id":410671,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"65862074330"},{"Id":410672,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"65862074390"},{"Id":410673,"FormularyType":"OHP","DrugName":"GALANTAMINE CAP 8MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030107020","GenericName":"GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG","NDC":"65862074430"},{"Id":410674,"FormularyType":"OHP","DrugName":"GALANTAMINE CAP 16MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030107030","GenericName":"GALANTAMINE HYDROBROMIDE CAP ER 24HR 16 MG","NDC":"65862074530"},{"Id":410675,"FormularyType":"OHP","DrugName":"GALANTAMINE CAP 24MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"24","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030107040","GenericName":"GALANTAMINE HYDROBROMIDE CAP ER 24HR 24 MG","NDC":"65862074630"},{"Id":410676,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"65862074760"},{"Id":410677,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"65862074860"},{"Id":410678,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"65862074960"},{"Id":410679,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"65862075060"},{"Id":410680,"FormularyType":"OHP","DrugName":"CEFIXIME SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060001910","GenericName":"CEFIXIME FOR SUSP 100 MG/5ML","NDC":"65862075150"},{"Id":410681,"FormularyType":"OHP","DrugName":"CEFIXIME SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060001920","GenericName":"CEFIXIME FOR SUSP 200 MG/5ML","NDC":"65862075250"},{"Id":410682,"FormularyType":"OHP","DrugName":"CEFIXIME SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060001920","GenericName":"CEFIXIME FOR SUSP 200 MG/5ML","NDC":"65862075275"},{"Id":410683,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"65862075360"},{"Id":410684,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"65862075890"},{"Id":410685,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"65862075990"},{"Id":410686,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"65862076090"},{"Id":410687,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"65862076190"},{"Id":410688,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"65862076290"},{"Id":410689,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"65862076390"},{"Id":410690,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"65862076490"},{"Id":410691,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"65862076590"},{"Id":410692,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"65862076890"},{"Id":410693,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"65862076990"},{"Id":410694,"FormularyType":"OHP","DrugName":"MILI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"65862077628"},{"Id":410695,"FormularyType":"OHP","DrugName":"MILI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"65862077685"},{"Id":410696,"FormularyType":"OHP","DrugName":"TRI-MILI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"65862077728"},{"Id":410697,"FormularyType":"OHP","DrugName":"TRI-MILI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"65862077785"},{"Id":410698,"FormularyType":"OHP","DrugName":"TRI-LO-MILI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"65862077828"},{"Id":410699,"FormularyType":"OHP","DrugName":"TRI-LO-MILI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"65862077885"},{"Id":410700,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"65862077930"},{"Id":410701,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"65862077990"},{"Id":410702,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"65862078030"},{"Id":410703,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"65862078090"},{"Id":410704,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"65862078130"},{"Id":410705,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"65862078190"},{"Id":410706,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"65862078390"},{"Id":410707,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"65862080205"},{"Id":410708,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"65862080210"},{"Id":410709,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"65862080244"},{"Id":410710,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100320","GenericName":"PRASUGREL HCL TAB 5 MG (BASE EQUIV)","NDC":"65862082930"},{"Id":410711,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100330","GenericName":"PRASUGREL HCL TAB 10 MG (BASE EQUIV)","NDC":"65862083030"},{"Id":410712,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"65862083105"},{"Id":410713,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"65862083130"},{"Id":410714,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"65862083205"},{"Id":410715,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"65862083230"},{"Id":410716,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"65862083305"},{"Id":410717,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"65862083330"},{"Id":410718,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"65862084003"},{"Id":410719,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"65862084130"},{"Id":410720,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"65862084230"},{"Id":410721,"FormularyType":"OHP","DrugName":"AYUNA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"65862084828"},{"Id":410722,"FormularyType":"OHP","DrugName":"AYUNA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"65862084888"},{"Id":410723,"FormularyType":"OHP","DrugName":"AFIRMELLE TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"65862084928"},{"Id":410724,"FormularyType":"OHP","DrugName":"AFIRMELLE TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"65862084988"},{"Id":410725,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"65862085825"},{"Id":410726,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"65862085830"},{"Id":410727,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"65862085860"},{"Id":410728,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"65862085901"},{"Id":410729,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"65862085999"},{"Id":410730,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"65862086001"},{"Id":410731,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"65862086099"},{"Id":410732,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"65862086360"},{"Id":410733,"FormularyType":"OHP","DrugName":"SIMPESSE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"65862086494"},{"Id":410734,"FormularyType":"OHP","DrugName":"SIMPESSE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"65862086495"},{"Id":410735,"FormularyType":"OHP","DrugName":"ICLEVIA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"65862086583"},{"Id":410736,"FormularyType":"OHP","DrugName":"ICLEVIA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"65862086594"},{"Id":410737,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"65862086703"},{"Id":410738,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"65862086710"},{"Id":410739,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"65862086730"},{"Id":410740,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"65862086803"},{"Id":410741,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"65862086810"},{"Id":410742,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"65862086830"},{"Id":410743,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"65862086903"},{"Id":410744,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"65862086910"},{"Id":410745,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"65862086930"},{"Id":410746,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"65862087003"},{"Id":410747,"FormularyType":"OHP","DrugName":"RISEDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042065100380","GenericName":"RISEDRONATE SODIUM TAB 150 MG","NDC":"65862087011"},{"Id":410748,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"65862087830"},{"Id":410749,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"65862087890"},{"Id":410750,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"65862087930"},{"Id":410751,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"65862087990"},{"Id":410752,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"65862088060"},{"Id":410753,"FormularyType":"OHP","DrugName":"SIMLIYA TAB 28 DAY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"65862088628"},{"Id":410754,"FormularyType":"OHP","DrugName":"SIMLIYA TAB 28 DAY","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"65862088688"},{"Id":410755,"FormularyType":"OHP","DrugName":"KALLIGA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"65862088728"},{"Id":410756,"FormularyType":"OHP","DrugName":"KALLIGA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"65862088788"},{"Id":410757,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"65862089130"},{"Id":410758,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"65862089230"},{"Id":410759,"FormularyType":"OHP","DrugName":"NYLIA TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"65862089728"},{"Id":410760,"FormularyType":"OHP","DrugName":"NYLIA TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"65862089788"},{"Id":410761,"FormularyType":"OHP","DrugName":"NYLIA TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"65862089888"},{"Id":410762,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"65862090525"},{"Id":410763,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"65862090530"},{"Id":410764,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"65862090560"},{"Id":410765,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"65862090801"},{"Id":410766,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"65862090805"},{"Id":410767,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"65862090901"},{"Id":410768,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"65862090905"},{"Id":410769,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"65862091406"},{"Id":410770,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"65862091469"},{"Id":410771,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"65862091503"},{"Id":410772,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"65862091564"},{"Id":410773,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"65862092127"},{"Id":410774,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"65862092201"},{"Id":410775,"FormularyType":"OHP","DrugName":"TRAMADL/APAP TAB 37.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65995002200320","GenericName":"TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG","NDC":"65862092205"},{"Id":410776,"FormularyType":"OHP","DrugName":"INCASSIA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"65862092585"},{"Id":410777,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"65862092730"},{"Id":410778,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"65862092790"},{"Id":410779,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"65862092901"},{"Id":410780,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"65862093008"},{"Id":410781,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"65862093090"},{"Id":410782,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"65862093108"},{"Id":410783,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"65862093190"},{"Id":410784,"FormularyType":"OHP","DrugName":"AUROVELA 24 TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"65862093487"},{"Id":410785,"FormularyType":"OHP","DrugName":"AUROVELA 24 TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"65862093488"},{"Id":410786,"FormularyType":"OHP","DrugName":"AUROVELA TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"65862093521"},{"Id":410787,"FormularyType":"OHP","DrugName":"AUROVELA TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"65862093574"},{"Id":410788,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 1 MCG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000110","GenericName":"PARICALCITOL CAP 1 MCG","NDC":"65862093630"},{"Id":410789,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 2 MCG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000120","GenericName":"PARICALCITOL CAP 2 MCG","NDC":"65862093730"},{"Id":410790,"FormularyType":"OHP","DrugName":"AUROVELA TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"65862093921"},{"Id":410791,"FormularyType":"OHP","DrugName":"AUROVELA TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"65862093988"},{"Id":410792,"FormularyType":"OHP","DrugName":"AUROVELA FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"65862094087"},{"Id":410793,"FormularyType":"OHP","DrugName":"AUROVELA FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"65862094088"},{"Id":410794,"FormularyType":"OHP","DrugName":"AUROVELA FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"65862094187"},{"Id":410795,"FormularyType":"OHP","DrugName":"AUROVELA FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"65862094188"},{"Id":410796,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"65862094601"},{"Id":410797,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"65862095230"},{"Id":410798,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"65862096701"},{"Id":410799,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"65862096730"},{"Id":410800,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"65862096801"},{"Id":410801,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"65862096830"},{"Id":410802,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"65862096901"},{"Id":410803,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"65862096930"},{"Id":410804,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"65862098601"},{"Id":410805,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"65862098605"},{"Id":410806,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"65862098701"},{"Id":410807,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"65862098799"},{"Id":410808,"FormularyType":"OHP","DrugName":"FLUMIST NASA LIQ 2025-26","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020500900","GenericName":"INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID","NDC":"66019011200"},{"Id":410809,"FormularyType":"OHP","DrugName":"FLUMIST NASA LIQ 2025-26","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020500900","GenericName":"INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID","NDC":"66019011210"},{"Id":410810,"FormularyType":"OHP","DrugName":"FLUMIST NASA LIQ 2025-26","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020500900","GenericName":"INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID","NDC":"66019011251"},{"Id":410811,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 100GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102180","GenericName":"CEFAZOLIN SODIUM (BULK) FOR INJ 100 GM","NDC":"66288110001"},{"Id":410812,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 300GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"300","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102190","GenericName":"CEFAZOLIN SODIUM (BULK) FOR INJ 300 GM","NDC":"66288130001"},{"Id":410813,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 100GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102180","GenericName":"CEFTRIAXONE SODIUM (BULK) FOR INJ 100 GM","NDC":"66288610001"},{"Id":410814,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 100GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102145","GenericName":"VANCOMYCIN HCL FOR IV SOLN 100 GM (BASE EQUIVALENT)","NDC":"66288710001"},{"Id":410815,"FormularyType":"OHP","DrugName":"REMODULIN INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"8","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002040","GenericName":"TREPROSTINIL INJ SOLN 8 MG/20ML (0.4 MG/ML)","NDC":"66302011401"},{"Id":410816,"FormularyType":"OHP","DrugName":"TYVASO ST KT SOL 0.6MG/ML","DosageForm":"SOLN - Solution","Strength":"0.6","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002020","GenericName":"TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML","NDC":"66302020601"},{"Id":410817,"FormularyType":"OHP","DrugName":"TYVASO RF KT SOL 0.6MG/ML","DosageForm":"SOLN - Solution","Strength":"0.6","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002020","GenericName":"TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML","NDC":"66302020602"},{"Id":410818,"FormularyType":"OHP","DrugName":"TYVASO SOL 0.6MG/ML","DosageForm":"SOLN - Solution","Strength":"0.6","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002020","GenericName":"TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML","NDC":"66302020603"},{"Id":410819,"FormularyType":"OHP","DrugName":"TYVASO ST KT SOL 0.6MG/ML","DosageForm":"SOLN - Solution","Strength":"0.6","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002020","GenericName":"TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML","NDC":"66302020604"},{"Id":410820,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 0.125MG","DosageForm":"TBCR - Tablet ER","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050410","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV)","NDC":"66302030001"},{"Id":410821,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 0.125MG","DosageForm":"TBCR - Tablet ER","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050410","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV)","NDC":"66302030002"},{"Id":410822,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 0.25MG","DosageForm":"TBCR - Tablet ER","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050415","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 0.25 MG (BASE EQUIV)","NDC":"66302030201"},{"Id":410823,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 0.25MG","DosageForm":"TBCR - Tablet ER","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050415","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 0.25 MG (BASE EQUIV)","NDC":"66302030202"},{"Id":410824,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 1MG","DosageForm":"TBCR - Tablet ER","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050420","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 1 MG (BASE EQUIV)","NDC":"66302031001"},{"Id":410825,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 1MG","DosageForm":"TBCR - Tablet ER","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050420","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 1 MG (BASE EQUIV)","NDC":"66302031002"},{"Id":410826,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 2.5MG","DosageForm":"TBCR - Tablet ER","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050425","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV)","NDC":"66302032501"},{"Id":410827,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 2.5MG","DosageForm":"TBCR - Tablet ER","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050425","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV)","NDC":"66302032502"},{"Id":410828,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 5MG","DosageForm":"TBCR - Tablet ER","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050435","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV)","NDC":"66302035001"},{"Id":410829,"FormularyType":"OHP","DrugName":"ORENITRAM TAB 5MG","DosageForm":"TBCR - Tablet ER","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080050435","GenericName":"TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV)","NDC":"66302035002"},{"Id":410830,"FormularyType":"OHP","DrugName":"ORENITRAM TAB MONTH 1","DosageForm":"TEPK - TBER Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4017008005C110","GenericName":"TREPROSTINIL TAB ER TITR PK (MO1) 126 X0.125MG & 42 X0.25MG","NDC":"66302036128"},{"Id":410831,"FormularyType":"OHP","DrugName":"ORENITRAM TAB MONTH 2","DosageForm":"TEPK - TBER Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4017008005C120","GenericName":"TREPROSTINIL TAB ER TITR PK (MO2) 126 X0.125MG & 210 X0.25MG","NDC":"66302036256"},{"Id":410832,"FormularyType":"OHP","DrugName":"ORENITRAM TAB MONTH 3","DosageForm":"TEPK - TBER Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4017008005C130","GenericName":"TREPROSTINIL TAB ER TITR PK(MO3)126X0.125MG&42X0.25MG&84X1MG","NDC":"66302036384"},{"Id":410833,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 16-32-48","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002980","GenericName":"TREPROSTINIL INH POWD 112 X 16MCG & 112 X 32MCG & 28 X 48MCG","NDC":"66302061002"},{"Id":410834,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 16MCG","DosageForm":"POWD - Powder","Strength":"16","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002920","GenericName":"TREPROSTINIL INH POWDER 16 MCG/CARTRIDGE","NDC":"66302061603"},{"Id":410835,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 32MCG","DosageForm":"POWD - Powder","Strength":"32","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002930","GenericName":"TREPROSTINIL INH POWDER 32 MCG/CARTRIDGE","NDC":"66302063203"},{"Id":410836,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 48MCG","DosageForm":"POWD - Powder","Strength":"48","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002940","GenericName":"TREPROSTINIL INH POWDER 48 MCG/CARTRIDGE","NDC":"66302064803"},{"Id":410837,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 64MCG","DosageForm":"POWD - Powder","Strength":"64","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002950","GenericName":"TREPROSTINIL INH POWDER 64 MCG/CARTRIDGE","NDC":"66302066403"},{"Id":410838,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 16MCG","DosageForm":"POWD - Powder","Strength":"16","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002920","GenericName":"TREPROSTINIL INH POWDER 16 MCG/CARTRIDGE","NDC":"66302071604"},{"Id":410839,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 32MCG","DosageForm":"POWD - Powder","Strength":"32","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002930","GenericName":"TREPROSTINIL INH POWDER 32 MCG/CARTRIDGE","NDC":"66302073204"},{"Id":410840,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 48MCG","DosageForm":"POWD - Powder","Strength":"48","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002940","GenericName":"TREPROSTINIL INH POWDER 48 MCG/CARTRIDGE","NDC":"66302074804"},{"Id":410841,"FormularyType":"OHP","DrugName":"TYVASO DPI POW 64MCG","DosageForm":"POWD - Powder","Strength":"64","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080002950","GenericName":"TREPROSTINIL INH POWDER 64 MCG/CARTRIDGE","NDC":"66302076404"},{"Id":410842,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"66424039610"},{"Id":410843,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"66424039901"},{"Id":410844,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"66424039910"},{"Id":410845,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"66424056208"},{"Id":410846,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"66685030200"},{"Id":410847,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"66685030202"},{"Id":410848,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"66685030300"},{"Id":410849,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"66685030400"},{"Id":410850,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"66685030402"},{"Id":410851,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"66685042100"},{"Id":410852,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"66685042101"},{"Id":410853,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"66689010601"},{"Id":410854,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"66689010650"},{"Id":410855,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"66689010699"},{"Id":410856,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"66689030516"},{"Id":410857,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"66689030708"},{"Id":410858,"FormularyType":"OHP","DrugName":"DIGOXIN SOL 50MCG/ML","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010002040","GenericName":"DIGOXIN ORAL SOLN 0.05 MG/ML","NDC":"66689032702"},{"Id":410859,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"66689034702"},{"Id":410860,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"66689040601"},{"Id":410861,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"66689040610"},{"Id":410862,"FormularyType":"OHP","DrugName":"MM PENTIPS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"66711000040"},{"Id":410863,"FormularyType":"OHP","DrugName":"MM PENTIPS MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"66711000041"},{"Id":410864,"FormularyType":"OHP","DrugName":"MM PENTIPS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"66711000042"},{"Id":410865,"FormularyType":"OHP","DrugName":"MM PENTIPS MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"66711000043"},{"Id":410866,"FormularyType":"OHP","DrugName":"CILOXAN OIN 0.3% OP","DosageForm":"OINT - Ointment","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023104210","GenericName":"CIPROFLOXACIN HCL OPHTH OINT 0.3%","NDC":"66758007138"},{"Id":410867,"FormularyType":"OHP","DrugName":"HYCAMTIN CAP 0.25MG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"TOPOISOMERASE I INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21550080100120","GenericName":"TOPOTECAN HCL CAP 0.25 MG (BASE EQUIV)","NDC":"66758010111"},{"Id":410868,"FormularyType":"OHP","DrugName":"HYCAMTIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"TOPOISOMERASE I INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21550080100140","GenericName":"TOPOTECAN HCL CAP 1 MG (BASE EQUIV)","NDC":"66758010211"},{"Id":410869,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"66794021943"},{"Id":410870,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"66794021963"},{"Id":410871,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"66794023643"},{"Id":410872,"FormularyType":"OHP","DrugName":"LINEZOLID INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040002040","GenericName":"LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML)","NDC":"66794023663"},{"Id":410873,"FormularyType":"OHP","DrugName":"NEOSPORIN+PN OIN RELF MAX","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"66968080109"},{"Id":410874,"FormularyType":"OHP","DrugName":"ESTRADIOL CRE 0.01%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020003705","GenericName":"ESTRADIOL VAGINAL CREAM 0.01%","NDC":"66993000210"},{"Id":410875,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"66993001968"},{"Id":410876,"FormularyType":"OHP","DrugName":"FLUTICAS HFA AER 44MCG","DosageForm":"AERO - Aerosol","Strength":"44","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400033223220","GenericName":"FLUTICASONE PROPIONATE HFA INHAL AERO 44 MCG/ACT","NDC":"66993007896"},{"Id":410877,"FormularyType":"OHP","DrugName":"FLUTICAS HFA AER 110MCG","DosageForm":"AERO - Aerosol","Strength":"110","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400033223230","GenericName":"FLUTICASONE PROPIONATE HFA INHAL AER 110 MCG/ACT","NDC":"66993007996"},{"Id":410878,"FormularyType":"OHP","DrugName":"FLUTICAS HFA AER 220MCG","DosageForm":"AERO - Aerosol","Strength":"220","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400033223240","GenericName":"FLUTICASONE PROPIONATE HFA INHAL AER 220 MCG/ACT","NDC":"66993008096"},{"Id":410879,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 5MG/ACT","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002010","GenericName":"SUMATRIPTAN NASAL SPRAY 5 MG/ACT","NDC":"66993008169"},{"Id":410880,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 20MG/ACT","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002040","GenericName":"SUMATRIPTAN NASAL SPRAY 20 MG/ACT","NDC":"66993008269"},{"Id":410881,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 45-21MCG","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703250","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT","NDC":"66993008696"},{"Id":410882,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 115-21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703260","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 115-21 MCG/ACT","NDC":"66993008796"},{"Id":410883,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 230-21","DosageForm":"AERO - Aerosol","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"44209902703270","GenericName":"FLUTICASONE-SALMETEROL INHAL AEROSOL 230-21 MCG/ACT","NDC":"66993008896"},{"Id":410884,"FormularyType":"OHP","DrugName":"UMECLID/VILA INH 62.5-25","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902958020","GenericName":"UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/ACT","NDC":"66993013497"},{"Id":410885,"FormularyType":"OHP","DrugName":"SPIRONO/HCTZ TAB 25/25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002200310","GenericName":"SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","NDC":"66993018802"},{"Id":410886,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"66993023360"},{"Id":410887,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"66993023460"},{"Id":410888,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"66993023560"},{"Id":410889,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"66993023630"},{"Id":410890,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"66993023730"},{"Id":410891,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"66993023830"},{"Id":410892,"FormularyType":"OHP","DrugName":"NITROGLYCRN SPR 400MCG","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030002060","GenericName":"NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)","NDC":"66993024141"},{"Id":410893,"FormularyType":"OHP","DrugName":"NITROGLYCRN SPR 400MCG","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030002060","GenericName":"NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)","NDC":"66993024150"},{"Id":410894,"FormularyType":"OHP","DrugName":"DAPAGLIF-MET TAB 5-1000MG","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307515","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 5-1000 MG","NDC":"66993036160"},{"Id":410895,"FormularyType":"OHP","DrugName":"DAPAGLIF-MET TAB 10-1000","DosageForm":"TB24 - Tablet ER 24HR","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27996002307525","GenericName":"DAPAGLIFLOZIN PROP-METFORMIN HCL TAB ER 24HR 10-1000 MG","NDC":"66993036230"},{"Id":410896,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"66993037025"},{"Id":410897,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"66993037083"},{"Id":410898,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2515003510E620","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML","NDC":"66993037179"},{"Id":410899,"FormularyType":"OHP","DrugName":"PHENYTOIN CHW 50MG","DosageForm":"CHEW - Tablet Chewable","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200030000505","GenericName":"PHENYTOIN CHEW TAB 50 MG","NDC":"66993037202"},{"Id":410900,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"66993042247"},{"Id":410901,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"66993042285"},{"Id":410902,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"66993042353"},{"Id":410903,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"66993042385"},{"Id":410904,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"66993042475"},{"Id":410905,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"66993042485"},{"Id":410906,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"66993043185"},{"Id":410907,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"66993043285"},{"Id":410908,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"66993043385"},{"Id":410909,"FormularyType":"OHP","DrugName":"DAPAGLIFLOZI TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200310","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG (BASE EQUIVALENT)","NDC":"66993045630"},{"Id":410910,"FormularyType":"OHP","DrugName":"DAPAGLIFLOZI TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"M","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27700040200320","GenericName":"DAPAGLIFLOZIN PROPANEDIOL TAB 10 MG (BASE EQUIVALENT)","NDC":"66993045730"},{"Id":410911,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 100/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708020","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/ACT","NDC":"66993058497"},{"Id":410912,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 250/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708030","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/ACT","NDC":"66993058597"},{"Id":410913,"FormularyType":"OHP","DrugName":"FLUTIC/SALME AER 500/50","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902708040","GenericName":"FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/ACT","NDC":"66993058697"},{"Id":410914,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"66993059402"},{"Id":410915,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"66993059502"},{"Id":410916,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"66993059702"},{"Id":410917,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"66993059902"},{"Id":410918,"FormularyType":"OHP","DrugName":"ETONOGESTREL MIS ETHY EST","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"66993060536"},{"Id":410919,"FormularyType":"OHP","DrugName":"ETONOGESTREL MIS ETHY EST","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"66993060581"},{"Id":410920,"FormularyType":"OHP","DrugName":"SMZ-TMP SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"66993072757"},{"Id":410921,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"66993073002"},{"Id":410922,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"66993073051"},{"Id":410923,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"66993073080"},{"Id":410924,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 3.75-23","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307020","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 3.75-23 MG","NDC":"66993078030"},{"Id":410925,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 7.5-46MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307030","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 7.5-46 MG","NDC":"66993078130"},{"Id":410926,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 11.25-69","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307040","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 11.25-69 MG","NDC":"66993078230"},{"Id":410927,"FormularyType":"OHP","DrugName":"PHENT/TOPIRA CAP 15-92MG","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANOREXIANTS NON-AMPHETAMINE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61209902307050","GenericName":"PHENTERMINE HCL-TOPIRAMATE CAP ER 24HR 15-92 MG","NDC":"66993078330"},{"Id":410928,"FormularyType":"OHP","DrugName":"FLUTICASONE AER 50MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400033208010","GenericName":"FLUTICASONE PROPIONATE AER POW BA 50 MCG/ACT","NDC":"66993079097"},{"Id":410929,"FormularyType":"OHP","DrugName":"FLUTICASONE AER 100MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400033208020","GenericName":"FLUTICASONE PROPIONATE AER POW BA 100 MCG/ACT","NDC":"66993079197"},{"Id":410930,"FormularyType":"OHP","DrugName":"FLUTICASONE AER 250MCG","DosageForm":"AEPB - Arsl Pwdr-Breath Activate","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400033208030","GenericName":"FLUTICASONE PROPIONATE AER POW BA 250 MCG/ACT","NDC":"66993079297"},{"Id":410931,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN CRE 0.005%","DosageForm":"CREA - Cream","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025003710","GenericName":"CALCIPOTRIENE CREAM 0.005%","NDC":"66993087761"},{"Id":410932,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN CRE 0.005%","DosageForm":"CREA - Cream","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025003710","GenericName":"CALCIPOTRIENE CREAM 0.005%","NDC":"66993087778"},{"Id":410933,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"66993095188"},{"Id":410934,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL PUMP 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004040","GenericName":"TESTOSTERONE TD GEL 12.5 MG/ACT (1%)","NDC":"66993095344"},{"Id":410935,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(25MG)","DosageForm":"GEL - Gel","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004025","GenericName":"TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","NDC":"66993095430"},{"Id":410936,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1%(50MG)","DosageForm":"GEL - Gel","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004030","GenericName":"TESTOSTERONE TD GEL 50 MG/5GM (1%)","NDC":"66993095530"},{"Id":410937,"FormularyType":"OHP","DrugName":"METRONIDAZOL CRE 0.75%","DosageForm":"CREA - Cream","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040003710","GenericName":"METRONIDAZOLE CREAM 0.75%","NDC":"66993096045"},{"Id":410938,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"67234001001"},{"Id":410939,"FormularyType":"OHP","DrugName":"PRO-EX ANTIF CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67234001401"},{"Id":410940,"FormularyType":"OHP","DrugName":"ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"67234002001"},{"Id":410941,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67234003101"},{"Id":410942,"FormularyType":"OHP","DrugName":"PROPYLTHIOUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300020000310","GenericName":"PROPYLTHIOURACIL TAB 50 MG","NDC":"67253065110"},{"Id":410943,"FormularyType":"OHP","DrugName":"PROPYLTHIOUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300020000310","GenericName":"PROPYLTHIOURACIL TAB 50 MG","NDC":"67253065111"},{"Id":410944,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"67457015300"},{"Id":410945,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"67457015303"},{"Id":410946,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"67457015309"},{"Id":410947,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"900","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002050","GenericName":"AMIODARONE HCL INJ 900 MG/18ML (50 MG/ML)","NDC":"67457015318"},{"Id":410948,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"67457015399"},{"Id":410949,"FormularyType":"OHP","DrugName":"CIDOFOVIR INJ 75MG/ML","DosageForm":"SOLN - Solution","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200010002020","GenericName":"CIDOFOVIR IV INJ 75 MG/ML","NDC":"67457021005"},{"Id":410950,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3017007010E510","GenericName":"OCTREOTIDE ACETATE SUBCUTANEOUS SOLN PREF SYR 100 MCG/ML","NDC":"67457024500"},{"Id":410951,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3017007010E510","GenericName":"OCTREOTIDE ACETATE SUBCUTANEOUS SOLN PREF SYR 100 MCG/ML","NDC":"67457024501"},{"Id":410952,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"67457029200"},{"Id":410953,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"67457029202"},{"Id":410954,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN INJ 400/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037122020","GenericName":"MOXIFLOXACIN HCL 400 MG/250ML IN SODIUM CHLORIDE 0.8% INJ","NDC":"67457032325"},{"Id":410955,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"67457033900"},{"Id":410956,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"67457033950"},{"Id":410957,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"67457034000"},{"Id":410958,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"67457034001"},{"Id":410959,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"67457034105"},{"Id":410960,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"67457034210"},{"Id":410961,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"67457037212"},{"Id":410962,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"67457037299"},{"Id":410963,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"67457037412"},{"Id":410964,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"67457037499"},{"Id":410965,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"67457038310"},{"Id":410966,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"67457038399"},{"Id":410967,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"67457038431"},{"Id":410968,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"67457038499"},{"Id":410969,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"67457038510"},{"Id":410970,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"67457038599"},{"Id":410971,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"67457040005"},{"Id":410972,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"67457040031"},{"Id":410973,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 1.2/30ML","DosageForm":"SOLN - Solution","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102038","GenericName":"TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","NDC":"67457042800"},{"Id":410974,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 1.2/30ML","DosageForm":"SOLN - Solution","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102038","GenericName":"TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","NDC":"67457042830"},{"Id":410975,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 80MG/2ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"67457047300"},{"Id":410976,"FormularyType":"OHP","DrugName":"TOBRAMYCIN INJ 80MG/2ML","DosageForm":"SOLN - Solution","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070102034","GenericName":"TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","NDC":"67457047322"},{"Id":410977,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"67457058200"},{"Id":410978,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"67457058210"},{"Id":410979,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"67457058300"},{"Id":410980,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"67457058304"},{"Id":410981,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"67457058400"},{"Id":410982,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"67457058406"},{"Id":410983,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"67457058500"},{"Id":410984,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"67457058508"},{"Id":410985,"FormularyType":"OHP","DrugName":"EPOPROSTENOL INJ 0.5MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170040102110","GenericName":"EPOPROSTENOL SODIUM FOR INJ 0.5 MG","NDC":"67457058710"},{"Id":410986,"FormularyType":"OHP","DrugName":"EPOPROSTENOL INJ 1.5MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170040102130","GenericName":"EPOPROSTENOL SODIUM FOR INJ 1.5 MG","NDC":"67457058810"},{"Id":410987,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"67457060202"},{"Id":410988,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"67457060299"},{"Id":410989,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"67457060305"},{"Id":410990,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"67457060399"},{"Id":410991,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"67457062199"},{"Id":410992,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 200/5ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"67457062299"},{"Id":410993,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 400/10ML","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"67457062399"},{"Id":410994,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"67457064500"},{"Id":410995,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"67457064502"},{"Id":410996,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"67457070500"},{"Id":410997,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"67457070575"},{"Id":410998,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"67457082312"},{"Id":410999,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"67457082399"},{"Id":411000,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"67457082415"},{"Id":411001,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"67457082499"},{"Id":411002,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"67457085400"},{"Id":411003,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 12MG/4ML","DosageForm":"SOLN - Solution","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002020","GenericName":"ADENOSINE IV SOLN 12 MG/4ML","NDC":"67457085404"},{"Id":411004,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"67457085500"},{"Id":411005,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"67457085502"},{"Id":411006,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102010","GenericName":"GRANISETRON HCL INJ 1 MG/ML","NDC":"67457086301"},{"Id":411007,"FormularyType":"OHP","DrugName":"GRANISETRON INJ 4MG/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035102015","GenericName":"GRANISETRON HCL INJ 4 MG/4ML (1 MG/ML)","NDC":"67457086404"},{"Id":411008,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"67457088700"},{"Id":411009,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"67457088701"},{"Id":411010,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"67457088799"},{"Id":411011,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"67457099202"},{"Id":411012,"FormularyType":"OHP","DrugName":"SLOWMAG MG TAB MUS/HRT","DosageForm":"TBEC - Tablet DR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79409902500630","GenericName":"MAGNESIUM CL-CA CARBONATE TAB DR 71.5-119 MG (ELEMENTAL)","NDC":"67618000005"},{"Id":411013,"FormularyType":"OHP","DrugName":"SLOW-MAG TAB","DosageForm":"TBEC - Tablet DR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79409902500630","GenericName":"MAGNESIUM CL-CA CARBONATE TAB DR 71.5-119 MG (ELEMENTAL)","NDC":"67618010760"},{"Id":411014,"FormularyType":"OHP","DrugName":"SLOW-MAG TAB 71.5-119","DosageForm":"TBEC - Tablet DR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79409902500630","GenericName":"MAGNESIUM CL-CA CARBONATE TAB DR 71.5-119 MG (ELEMENTAL)","NDC":"67618011220"},{"Id":411015,"FormularyType":"OHP","DrugName":"SLOWMAG MG TAB MUS/HRT","DosageForm":"TBEC - Tablet DR","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79409902500630","GenericName":"MAGNESIUM CL-CA CARBONATE TAB DR 71.5-119 MG (ELEMENTAL)","NDC":"67618011280"},{"Id":411016,"FormularyType":"OHP","DrugName":"BIOLYTE SOL CITRUS","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000020"},{"Id":411017,"FormularyType":"OHP","DrugName":"BIOLYTE SOL CITRUS","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000021"},{"Id":411018,"FormularyType":"OHP","DrugName":"BIOLYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000024"},{"Id":411019,"FormularyType":"OHP","DrugName":"BIOLYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000025"},{"Id":411020,"FormularyType":"OHP","DrugName":"BIOLYTE SOL TROPICAL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000026"},{"Id":411021,"FormularyType":"OHP","DrugName":"BIOLYTE SOL TROPICAL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000027"},{"Id":411022,"FormularyType":"OHP","DrugName":"BIOLYTE SOL MELON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000028"},{"Id":411023,"FormularyType":"OHP","DrugName":"BIOLYTE SOL MELON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"67693000029"},{"Id":411024,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"67777000401"},{"Id":411025,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"67777000402"},{"Id":411026,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"67777000403"},{"Id":411027,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"67777000404"},{"Id":411028,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000810"},{"Id":411029,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000811"},{"Id":411030,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000820"},{"Id":411031,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000821"},{"Id":411032,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000830"},{"Id":411033,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000831"},{"Id":411034,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000850"},{"Id":411035,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000851"},{"Id":411036,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000860"},{"Id":411037,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"67777000861"},{"Id":411038,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"67777011610"},{"Id":411039,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"67777011611"},{"Id":411040,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"67777011620"},{"Id":411041,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"67777011621"},{"Id":411042,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"67777011630"},{"Id":411043,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"67777011631"},{"Id":411044,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012113"},{"Id":411045,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012114"},{"Id":411046,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012116"},{"Id":411047,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012117"},{"Id":411048,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012118"},{"Id":411049,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012119"},{"Id":411050,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777012120"},{"Id":411051,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021701"},{"Id":411052,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021710"},{"Id":411053,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021711"},{"Id":411054,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021712"},{"Id":411055,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021713"},{"Id":411056,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021714"},{"Id":411057,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021715"},{"Id":411058,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021716"},{"Id":411059,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"67777021717"},{"Id":411060,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"67777022302"},{"Id":411061,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"67777022304"},{"Id":411062,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"67777022311"},{"Id":411063,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"67777022313"},{"Id":411064,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67777023101"},{"Id":411065,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67777023102"},{"Id":411066,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67777023110"},{"Id":411067,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67777023111"},{"Id":411068,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67777023112"},{"Id":411069,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"67777023113"},{"Id":411070,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777030001"},{"Id":411071,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"67777030002"},{"Id":411072,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"67777031601"},{"Id":411073,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"67777031602"},{"Id":411074,"FormularyType":"OHP","DrugName":"WE CARE ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"67777040201"},{"Id":411075,"FormularyType":"OHP","DrugName":"WE CARE ENE ENEMA","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"67777040202"},{"Id":411076,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"67877012405"},{"Id":411077,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"67877012420"},{"Id":411078,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"67877012425"},{"Id":411079,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"67877012440"},{"Id":411080,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"67877012450"},{"Id":411081,"FormularyType":"OHP","DrugName":"SILVER SULFA CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"BURN PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90450030003710","GenericName":"SILVER SULFADIAZINE CREAM 1%","NDC":"67877012485"},{"Id":411082,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"67877015901"},{"Id":411083,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"67877015905"},{"Id":411084,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"67877017030"},{"Id":411085,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"67877019705"},{"Id":411086,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"67877019805"},{"Id":411087,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"67877019810"},{"Id":411088,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"67877019905"},{"Id":411089,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"67877019990"},{"Id":411090,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"67877021520"},{"Id":411091,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050310","GenericName":"CEFUROXIME AXETIL TAB 250 MG","NDC":"67877021560"},{"Id":411092,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"67877021620"},{"Id":411093,"FormularyType":"OHP","DrugName":"CEFUROXIME TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200065050315","GenericName":"CEFUROXIME AXETIL TAB 500 MG","NDC":"67877021660"},{"Id":411094,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"67877021805"},{"Id":411095,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"67877021810"},{"Id":411096,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"67877021901"},{"Id":411097,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"67877021905"},{"Id":411098,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"67877021984"},{"Id":411099,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"67877022001"},{"Id":411100,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"67877022005"},{"Id":411101,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"67877022201"},{"Id":411102,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"67877022205"},{"Id":411103,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"67877022210"},{"Id":411104,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"67877022301"},{"Id":411105,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"67877022305"},{"Id":411106,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"67877022310"},{"Id":411107,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"67877022401"},{"Id":411108,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"67877022405"},{"Id":411109,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"67877022410"},{"Id":411110,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"67877022501"},{"Id":411111,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"67877022505"},{"Id":411112,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"67877023022"},{"Id":411113,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"67877024350"},{"Id":411114,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"67877024401"},{"Id":411115,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"67877025115"},{"Id":411116,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"67877025130"},{"Id":411117,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"67877025145"},{"Id":411118,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"67877025180"},{"Id":411119,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"67877025690"},{"Id":411120,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"67877025790"},{"Id":411121,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"67877025890"},{"Id":411122,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"67877026106"},{"Id":411123,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"67877026118"},{"Id":411124,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"67877026125"},{"Id":411125,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"67877026206"},{"Id":411126,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"67877026218"},{"Id":411127,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"67877026225"},{"Id":411128,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"67877026601"},{"Id":411129,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"67877026605"},{"Id":411130,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"67877027430"},{"Id":411131,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"67877027505"},{"Id":411132,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"67877027530"},{"Id":411133,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"67877027590"},{"Id":411134,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"67877027605"},{"Id":411135,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"67877027690"},{"Id":411136,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"67877027801"},{"Id":411137,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"67877027901"},{"Id":411138,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"67877028001"},{"Id":411139,"FormularyType":"OHP","DrugName":"RILUZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74503070000320","GenericName":"RILUZOLE TAB 50 MG","NDC":"67877028660"},{"Id":411140,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"67877028801"},{"Id":411141,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"67877028805"},{"Id":411142,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"67877028810"},{"Id":411143,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"67877028830"},{"Id":411144,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"67877028890"},{"Id":411145,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877029501"},{"Id":411146,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877029505"},{"Id":411147,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877029530"},{"Id":411148,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877029550"},{"Id":411149,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877029601"},{"Id":411150,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877029605"},{"Id":411151,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877029630"},{"Id":411152,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877029650"},{"Id":411153,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"67877029809"},{"Id":411154,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"67877029837"},{"Id":411155,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"67877029860"},{"Id":411156,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"67877031715"},{"Id":411157,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"67877031745"},{"Id":411158,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103705","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.025%","NDC":"67877031780"},{"Id":411159,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103720","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.5%","NDC":"67877031815"},{"Id":411160,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"67877031901"},{"Id":411161,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"67877031905"},{"Id":411162,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877032001"},{"Id":411163,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877032005"},{"Id":411164,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877032030"},{"Id":411165,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"67877032050"},{"Id":411166,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877032101"},{"Id":411167,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877032105"},{"Id":411168,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877032130"},{"Id":411169,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"67877032150"},{"Id":411170,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"67877041301"},{"Id":411171,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"67877041305"},{"Id":411172,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"67877041390"},{"Id":411173,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"67877041401"},{"Id":411174,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"67877041405"},{"Id":411175,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"67877041530"},{"Id":411176,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"67877041690"},{"Id":411177,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"67877041790"},{"Id":411178,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"67877041890"},{"Id":411179,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"67877041901"},{"Id":411180,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"67877041920"},{"Id":411181,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"67877041933"},{"Id":411182,"FormularyType":"OHP","DrugName":"LINEZOLID TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"OXAZOLIDINONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16230040000330","GenericName":"LINEZOLID TAB 600 MG","NDC":"67877041984"},{"Id":411183,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"67877042260"},{"Id":411184,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"67877042612"},{"Id":411185,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"67877042712"},{"Id":411186,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"67877042801"},{"Id":411187,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"67877042805"},{"Id":411188,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"67877042901"},{"Id":411189,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"67877042905"},{"Id":411190,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"67877043905"},{"Id":411191,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"67877043990"},{"Id":411192,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"67877044005"},{"Id":411193,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"67877044090"},{"Id":411194,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"67877044105"},{"Id":411195,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"67877044190"},{"Id":411196,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"67877044205"},{"Id":411197,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"67877044230"},{"Id":411198,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"67877044290"},{"Id":411199,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"67877044330"},{"Id":411200,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"67877044390"},{"Id":411201,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"67877044460"},{"Id":411202,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"67877044530"},{"Id":411203,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"67877044630"},{"Id":411204,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"67877044690"},{"Id":411205,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"67877044730"},{"Id":411206,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"67877044790"},{"Id":411207,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"67877045001"},{"Id":411208,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"67877045005"},{"Id":411209,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"67877045010"},{"Id":411210,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"67877045130"},{"Id":411211,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"67877045190"},{"Id":411212,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"67877045230"},{"Id":411213,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"67877045290"},{"Id":411214,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"67877045330"},{"Id":411215,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"67877045390"},{"Id":411216,"FormularyType":"OHP","DrugName":"ITRACONAZOLE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407035000120","GenericName":"ITRACONAZOLE CAP 100 MG","NDC":"67877045430"},{"Id":411217,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"67877045505"},{"Id":411218,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"67877045530"},{"Id":411219,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"HAIR GROWTH AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90736030000310","GenericName":"FINASTERIDE TAB 1 MG","NDC":"67877045590"},{"Id":411220,"FormularyType":"OHP","DrugName":"PREGABALIN SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057002020","GenericName":"PREGABALIN SOLN 20 MG/ML","NDC":"67877045747"},{"Id":411221,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"67877045860"},{"Id":411222,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"67877045912"},{"Id":411223,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"67877046205"},{"Id":411224,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"67877046290"},{"Id":411225,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"67877046305"},{"Id":411226,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"67877046390"},{"Id":411227,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"67877046405"},{"Id":411228,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"67877046490"},{"Id":411229,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"67877046505"},{"Id":411230,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"67877046590"},{"Id":411231,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"67877046605"},{"Id":411232,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"67877046690"},{"Id":411233,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"67877046705"},{"Id":411234,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"67877046790"},{"Id":411235,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"67877046805"},{"Id":411236,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"67877046890"},{"Id":411237,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"67877046905"},{"Id":411238,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"67877046990"},{"Id":411239,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"67877047460"},{"Id":411240,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"67877047560"},{"Id":411241,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"67877047630"},{"Id":411242,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"67877047750"},{"Id":411243,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"67877047810"},{"Id":411244,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"67877047830"},{"Id":411245,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"67877047890"},{"Id":411246,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"67877047910"},{"Id":411247,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"67877047930"},{"Id":411248,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"67877047990"},{"Id":411249,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"67877048090"},{"Id":411250,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"67877048230"},{"Id":411251,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"67877048330"},{"Id":411252,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"67877048430"},{"Id":411253,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"67877049005"},{"Id":411254,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"67877049030"},{"Id":411255,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"67877049090"},{"Id":411256,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"67877049301"},{"Id":411257,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"67877049305"},{"Id":411258,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"67877050330"},{"Id":411259,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"67877050430"},{"Id":411260,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"67877050530"},{"Id":411261,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"67877051105"},{"Id":411262,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"67877051110"},{"Id":411263,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"67877051190"},{"Id":411264,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"67877051205"},{"Id":411265,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"67877051210"},{"Id":411266,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"67877051290"},{"Id":411267,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"67877051305"},{"Id":411268,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"67877051310"},{"Id":411269,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"67877051390"},{"Id":411270,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"67877051405"},{"Id":411271,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"67877051490"},{"Id":411272,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"67877052560"},{"Id":411273,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"67877052660"},{"Id":411274,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"67877052730"},{"Id":411275,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"67877052790"},{"Id":411276,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"67877052830"},{"Id":411277,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"67877052890"},{"Id":411278,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"67877053258"},{"Id":411279,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"67877053707"},{"Id":411280,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"67877053714"},{"Id":411281,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"67877053807"},{"Id":411282,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"67877053814"},{"Id":411283,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"67877053907"},{"Id":411284,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"67877053914"},{"Id":411285,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"67877054007"},{"Id":411286,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"67877054014"},{"Id":411287,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"67877054107"},{"Id":411288,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"67877054114"},{"Id":411289,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"67877054207"},{"Id":411290,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"67877054360"},{"Id":411291,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"67877054468"},{"Id":411292,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"67877054488"},{"Id":411293,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"67877054568"},{"Id":411294,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"67877054588"},{"Id":411295,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"67877054788"},{"Id":411296,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"67877054798"},{"Id":411297,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"67877054888"},{"Id":411298,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"67877054898"},{"Id":411299,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 125MG","DosageForm":"TBSO - Tablet Soluble","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007320","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 125 MG","NDC":"67877054930"},{"Id":411300,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 250MG","DosageForm":"TBSO - Tablet Soluble","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007330","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 250 MG","NDC":"67877055030"},{"Id":411301,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 500MG","DosageForm":"TBSO - Tablet Soluble","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007340","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 500 MG","NDC":"67877055130"},{"Id":411302,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"67877055230"},{"Id":411303,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"67877055430"},{"Id":411304,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"67877055514"},{"Id":411305,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"67877055660"},{"Id":411306,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP STARTER","DosageForm":"CDPK - CPDR Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240552500B320","GenericName":"DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG","NDC":"67877055739"},{"Id":411307,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"67877056110"},{"Id":411308,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"67877056205"},{"Id":411309,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"67877056210"},{"Id":411310,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"67877056301"},{"Id":411311,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"67877057130"},{"Id":411312,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"67877057190"},{"Id":411313,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"67877057210"},{"Id":411314,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"67877057230"},{"Id":411315,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"67877057290"},{"Id":411316,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"67877057301"},{"Id":411317,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"67877057305"},{"Id":411318,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"67877057501"},{"Id":411319,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"67877057505"},{"Id":411320,"FormularyType":"OHP","DrugName":"CEFIXIME CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060000120","GenericName":"CEFIXIME CAP 400 MG","NDC":"67877058433"},{"Id":411321,"FormularyType":"OHP","DrugName":"CEFIXIME CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060000120","GenericName":"CEFIXIME CAP 400 MG","NDC":"67877058450"},{"Id":411322,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"67877058901"},{"Id":411323,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"67877059001"},{"Id":411324,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"67877059005"},{"Id":411325,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"67877059101"},{"Id":411326,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"67877059105"},{"Id":411327,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"67877059201"},{"Id":411328,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"67877059205"},{"Id":411329,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"67877059301"},{"Id":411330,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"67877059305"},{"Id":411331,"FormularyType":"OHP","DrugName":"PRASUGREL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158060100330","GenericName":"PRASUGREL HCL TAB 10 MG (BASE EQUIV)","NDC":"67877060530"},{"Id":411332,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"67877061315"},{"Id":411333,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"67877061415"},{"Id":411334,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"67877061601"},{"Id":411335,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"67877061701"},{"Id":411336,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"67877061801"},{"Id":411337,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"67877062460"},{"Id":411338,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"67877063390"},{"Id":411339,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"67877063430"},{"Id":411340,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"67877063502"},{"Id":411341,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"67877063533"},{"Id":411342,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"67877063602"},{"Id":411343,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"67877063633"},{"Id":411344,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100320","GenericName":"DEXMETHYLPHENIDATE HCL TAB 2.5 MG","NDC":"67877065501"},{"Id":411345,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100330","GenericName":"DEXMETHYLPHENIDATE HCL TAB 5 MG","NDC":"67877065601"},{"Id":411346,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100340","GenericName":"DEXMETHYLPHENIDATE HCL TAB 10 MG","NDC":"67877065701"},{"Id":411347,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"67877065861"},{"Id":411348,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"67877066501"},{"Id":411349,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"67877066601"},{"Id":411350,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100310","GenericName":"MORPHINE SULFATE TAB 15 MG","NDC":"67877067001"},{"Id":411351,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100315","GenericName":"MORPHINE SULFATE TAB 30 MG","NDC":"67877067101"},{"Id":411352,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"67877067463"},{"Id":411353,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"67877067870"},{"Id":411354,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"67877069601"},{"Id":411355,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"67877069610"},{"Id":411356,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"67877069701"},{"Id":411357,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"67877070751"},{"Id":411358,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"67877070760"},{"Id":411359,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"67877070860"},{"Id":411360,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"67877070960"},{"Id":411361,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"67877071712"},{"Id":411362,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"67877071831"},{"Id":411363,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"67877071833"},{"Id":411364,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"67877071931"},{"Id":411365,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"67877071933"},{"Id":411366,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"67877072031"},{"Id":411367,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"67877072033"},{"Id":411368,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"67877072131"},{"Id":411369,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"67877072133"},{"Id":411370,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"67877073032"},{"Id":411371,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"67877073093"},{"Id":411372,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"67877073295"},{"Id":411373,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"67877073360"},{"Id":411374,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"67877073460"},{"Id":411375,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"67877073560"},{"Id":411376,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"67877073660"},{"Id":411377,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"67877074395"},{"Id":411378,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"67877074495"},{"Id":411379,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"67877074554"},{"Id":411380,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000310","GenericName":"SIROLIMUS TAB 0.5 MG","NDC":"67877074601"},{"Id":411381,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"67877074701"},{"Id":411382,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000330","GenericName":"SIROLIMUS TAB 2 MG","NDC":"67877074801"},{"Id":411383,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"67877074957"},{"Id":411384,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 25MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102160","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 25 MG/ML (BASE EQUIVALENT)","NDC":"67877075058"},{"Id":411385,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 25MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102160","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 25 MG/ML (BASE EQUIVALENT)","NDC":"67877075081"},{"Id":411386,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"67877075158"},{"Id":411387,"FormularyType":"OHP","DrugName":"VANCOMYCIN SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102170","GenericName":"VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT)","NDC":"67877075181"},{"Id":411388,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000110","GenericName":"DRONABINOL CAP 2.5 MG","NDC":"67877075360"},{"Id":411389,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000115","GenericName":"DRONABINOL CAP 5 MG","NDC":"67877075460"},{"Id":411390,"FormularyType":"OHP","DrugName":"DRONABINOL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - MISCELLANEOUS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50300030000120","GenericName":"DRONABINOL CAP 10 MG","NDC":"67877075560"},{"Id":411391,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007580","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","NDC":"67877075601"},{"Id":411392,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"67877075701"},{"Id":411393,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"67877075758"},{"Id":411394,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"67877075801"},{"Id":411395,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"67877075858"},{"Id":411396,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"67877076805"},{"Id":411397,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"67877076812"},{"Id":411398,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"67877076905"},{"Id":411399,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"67877076912"},{"Id":411400,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"67877077005"},{"Id":411401,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"67877077012"},{"Id":411402,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"67877077160"},{"Id":411403,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"67877077589"},{"Id":411404,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"67877084201"},{"Id":411405,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"67877084205"},{"Id":411406,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"67877084210"},{"Id":411407,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006820","GenericName":"TOPIRAMATE SPRINKLE CAP 15 MG","NDC":"67877086860"},{"Id":411408,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 25MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006830","GenericName":"TOPIRAMATE SPRINKLE CAP 25 MG","NDC":"67877086960"},{"Id":411409,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100320","GenericName":"CEFPODOXIME PROXETIL TAB 100 MG","NDC":"67877087820"},{"Id":411410,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100330","GenericName":"CEFPODOXIME PROXETIL TAB 200 MG","NDC":"67877087920"},{"Id":411411,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"67877088901"},{"Id":411412,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"67877088905"},{"Id":411413,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"67877090010"},{"Id":411414,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"67877090090"},{"Id":411415,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"67877090190"},{"Id":411416,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"67877090210"},{"Id":411417,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"67877093001"},{"Id":411418,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"67877093005"},{"Id":411419,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"67877093101"},{"Id":411420,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"67877093205"},{"Id":411421,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"67877093210"},{"Id":411422,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"67877094951"},{"Id":411423,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"67877094960"},{"Id":411424,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"67877095051"},{"Id":411425,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"67877095060"},{"Id":411426,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"68001011104"},{"Id":411427,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"68001011105"},{"Id":411428,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"68001011203"},{"Id":411429,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"68001011204"},{"Id":411430,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"68001011205"},{"Id":411431,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007520","GenericName":"LEVETIRACETAM TAB ER 24HR 500 MG","NDC":"68001011306"},{"Id":411432,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"68001011406"},{"Id":411433,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68001011903"},{"Id":411434,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"68001013000"},{"Id":411435,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"68001013100"},{"Id":411436,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 2.5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200120","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","NDC":"68001013200"},{"Id":411437,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"68001013300"},{"Id":411438,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"68001013400"},{"Id":411439,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200145","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","NDC":"68001013500"},{"Id":411440,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"68001015100"},{"Id":411441,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"68001015103"},{"Id":411442,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"68001015200"},{"Id":411443,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"68001015203"},{"Id":411444,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"68001015300"},{"Id":411445,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"68001015303"},{"Id":411446,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"68001015400"},{"Id":411447,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"68001015403"},{"Id":411448,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"68001015504"},{"Id":411449,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"68001015508"},{"Id":411450,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100305","GenericName":"PROMETHAZINE HCL TAB 12.5 MG","NDC":"68001016100"},{"Id":411451,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"68001016200"},{"Id":411452,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"68001016203"},{"Id":411453,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100315","GenericName":"PROMETHAZINE HCL TAB 50 MG","NDC":"68001016300"},{"Id":411454,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"68001023700"},{"Id":411455,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100305","GenericName":"CLONIDINE HCL TAB 0.1 MG","NDC":"68001023703"},{"Id":411456,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"68001023800"},{"Id":411457,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100310","GenericName":"CLONIDINE HCL TAB 0.2 MG","NDC":"68001023803"},{"Id":411458,"FormularyType":"OHP","DrugName":"CLONIDINE TAB 0.3MG","DosageForm":"TABS - Tablet","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201010100315","GenericName":"CLONIDINE HCL TAB 0.3 MG","NDC":"68001023900"},{"Id":411459,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"68001024200"},{"Id":411460,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"68001024300"},{"Id":411461,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"68001024400"},{"Id":411462,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"68001024403"},{"Id":411463,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"68001024604"},{"Id":411464,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"68001024616"},{"Id":411465,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"68001024617"},{"Id":411466,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"68001024704"},{"Id":411467,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"68001024716"},{"Id":411468,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"68001024717"},{"Id":411469,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"68001024901"},{"Id":411470,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"68001024919"},{"Id":411471,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"68001025001"},{"Id":411472,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"68001025018"},{"Id":411473,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"68001025104"},{"Id":411474,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"68001025204"},{"Id":411475,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"68001025317"},{"Id":411476,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"68001025344"},{"Id":411477,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"68001025404"},{"Id":411478,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 25MG DR","DosageForm":"TBEC - Tablet DR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200610","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG","NDC":"68001027900"},{"Id":411479,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"68001028000"},{"Id":411480,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"68001028006"},{"Id":411481,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"68001028008"},{"Id":411482,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"68001028100"},{"Id":411483,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"68001028103"},{"Id":411484,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"68001028106"},{"Id":411485,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"68001028108"},{"Id":411486,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"68001031400"},{"Id":411487,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68001031500"},{"Id":411488,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68001031508"},{"Id":411489,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68001031600"},{"Id":411490,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68001031608"},{"Id":411491,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"68001032700"},{"Id":411492,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"68001032703"},{"Id":411493,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"68001032800"},{"Id":411494,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"68001032803"},{"Id":411495,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"68001033200"},{"Id":411496,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"68001033203"},{"Id":411497,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"68001033300"},{"Id":411498,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"68001033308"},{"Id":411499,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"68001033400"},{"Id":411500,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"68001033408"},{"Id":411501,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"68001033500"},{"Id":411502,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"68001033508"},{"Id":411503,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"68001033600"},{"Id":411504,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68001035600"},{"Id":411505,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68001035603"},{"Id":411506,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"68001036103"},{"Id":411507,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"68001036104"},{"Id":411508,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"68001036105"},{"Id":411509,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"68001036206"},{"Id":411510,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"68001036400"},{"Id":411511,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"68001036500"},{"Id":411512,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"68001036503"},{"Id":411513,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"68001037300"},{"Id":411514,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"68001037400"},{"Id":411515,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"68001037500"},{"Id":411516,"FormularyType":"OHP","DrugName":"URSODIOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000325","GenericName":"URSODIOL TAB 250 MG","NDC":"68001037700"},{"Id":411517,"FormularyType":"OHP","DrugName":"URSODIOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000350","GenericName":"URSODIOL TAB 500 MG","NDC":"68001037800"},{"Id":411518,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"68001038100"},{"Id":411519,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"68001038103"},{"Id":411520,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"68001038200"},{"Id":411521,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"68001038203"},{"Id":411522,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"68001038300"},{"Id":411523,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"68001038303"},{"Id":411524,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"68001039700"},{"Id":411525,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"68001039708"},{"Id":411526,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"68001039800"},{"Id":411527,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"68001039803"},{"Id":411528,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"68001040203"},{"Id":411529,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"68001040207"},{"Id":411530,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"68001040303"},{"Id":411531,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"68001040307"},{"Id":411532,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"68001040403"},{"Id":411533,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"68001040407"},{"Id":411534,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"68001040506"},{"Id":411535,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"68001040775"},{"Id":411536,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"68001040829"},{"Id":411537,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"68001040831"},{"Id":411538,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68001041100"},{"Id":411539,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68001041103"},{"Id":411540,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68001041200"},{"Id":411541,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68001041203"},{"Id":411542,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"68001042800"},{"Id":411543,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"68001042900"},{"Id":411544,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68001043000"},{"Id":411545,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68001043003"},{"Id":411546,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68001043100"},{"Id":411547,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68001043103"},{"Id":411548,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 3","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"68001043288"},{"Id":411549,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 3","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"68001043290"},{"Id":411550,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"68001043388"},{"Id":411551,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"68001043390"},{"Id":411552,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 1","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"68001043488"},{"Id":411553,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 1","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"68001043490"},{"Id":411554,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 1","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"68001043491"},{"Id":411555,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"68001043604"},{"Id":411556,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"68001043616"},{"Id":411557,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"68001043696"},{"Id":411558,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"68001043697"},{"Id":411559,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"68001043800"},{"Id":411560,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"68001043804"},{"Id":411561,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"68001043816"},{"Id":411562,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"68001043896"},{"Id":411563,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"68001043897"},{"Id":411564,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"68001043900"},{"Id":411565,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"68001044000"},{"Id":411566,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"68001044004"},{"Id":411567,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"68001044998"},{"Id":411568,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68001046900"},{"Id":411569,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68001047000"},{"Id":411570,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"68001047100"},{"Id":411571,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"68001047545"},{"Id":411572,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"68001047547"},{"Id":411573,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"68001047646"},{"Id":411574,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"68001047650"},{"Id":411575,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"68001047745"},{"Id":411576,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"68001047746"},{"Id":411577,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"68001047747"},{"Id":411578,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010004210","GenericName":"BACITRACIN OINT 500 UNIT/GM","NDC":"68001047748"},{"Id":411579,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"68001048145"},{"Id":411580,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"68001048147"},{"Id":411581,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"68001048148"},{"Id":411582,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"68001048345"},{"Id":411583,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"68001048346"},{"Id":411584,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"68001048600"},{"Id":411585,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"68001048608"},{"Id":411586,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"68001048907"},{"Id":411587,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"68001049404"},{"Id":411588,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"68001049406"},{"Id":411589,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"68001049500"},{"Id":411590,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68001050000"},{"Id":411591,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68001050003"},{"Id":411592,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68001050100"},{"Id":411593,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68001050103"},{"Id":411594,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68001050200"},{"Id":411595,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68001050203"},{"Id":411596,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"68001050300"},{"Id":411597,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"68001050555"},{"Id":411598,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350 NF","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"68001050569"},{"Id":411599,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"68001050628"},{"Id":411600,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"68001050630"},{"Id":411601,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"68001050753"},{"Id":411602,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"68001050782"},{"Id":411603,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"68001050829"},{"Id":411604,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"68001050831"},{"Id":411605,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"68001051800"},{"Id":411606,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"68001051808"},{"Id":411607,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"68001052192"},{"Id":411608,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"68001052194"},{"Id":411609,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"68001052900"},{"Id":411610,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"68001052908"},{"Id":411611,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"68001053145"},{"Id":411612,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"68001053146"},{"Id":411613,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"68001053245"},{"Id":411614,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"68001053246"},{"Id":411615,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"68001053350"},{"Id":411616,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"68001056200"},{"Id":411617,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"68001056600"},{"Id":411618,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"68001056603"},{"Id":411619,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"68001056700"},{"Id":411620,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"68001056703"},{"Id":411621,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100310","GenericName":"DESMOPRESSIN ACETATE TAB 0.1 MG","NDC":"68001057400"},{"Id":411622,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100320","GenericName":"DESMOPRESSIN ACETATE TAB 0.2 MG","NDC":"68001057500"},{"Id":411623,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"68001058400"},{"Id":411624,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"68001058403"},{"Id":411625,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"68001058500"},{"Id":411626,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"68001058503"},{"Id":411627,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"68001058600"},{"Id":411628,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"68001058603"},{"Id":411629,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"68001059705"},{"Id":411630,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100110","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG","NDC":"68001060300"},{"Id":411631,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"68001060400"},{"Id":411632,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"68001060500"},{"Id":411633,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"68001060600"},{"Id":411634,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"68001060755"},{"Id":411635,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"68001060769"},{"Id":411636,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007207530","GenericName":"DICLOFENAC SODIUM TAB ER 24HR 100 MG","NDC":"68001061200"},{"Id":411637,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"68001061900"},{"Id":411638,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"68001061903"},{"Id":411639,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"68001062145"},{"Id":411640,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"68001062205"},{"Id":411641,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"68001062304"},{"Id":411642,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210003000B705","GenericName":"METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","NDC":"68001062401"},{"Id":411643,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"68001063000"},{"Id":411644,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"68001063100"},{"Id":411645,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"68001063200"},{"Id":411646,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"68001063342"},{"Id":411647,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"68001063343"},{"Id":411648,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"68001063442"},{"Id":411649,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"68001063443"},{"Id":411650,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"68001063542"},{"Id":411651,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"68001063543"},{"Id":411652,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80MG/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"68001063642"},{"Id":411653,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80MG/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"68001063643"},{"Id":411654,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"68001063742"},{"Id":411655,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"68001063743"},{"Id":411656,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"68001063842"},{"Id":411657,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"68001063843"},{"Id":411658,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"68001063942"},{"Id":411659,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"68001063943"},{"Id":411660,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"68001064059"},{"Id":411661,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"68001064060"},{"Id":411662,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 300/3ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101020102050","GenericName":"ENOXAPARIN SODIUM INJ 300 MG/3ML","NDC":"68001064141"},{"Id":411663,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"68001064306"},{"Id":411664,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"68001064407"},{"Id":411665,"FormularyType":"OHP","DrugName":"NALOXONE SPR","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"68001064545"},{"Id":411666,"FormularyType":"OHP","DrugName":"ZENATANE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"68001065216"},{"Id":411667,"FormularyType":"OHP","DrugName":"ZENATANE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"68001065217"},{"Id":411668,"FormularyType":"OHP","DrugName":"ZENATANE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"68001065316"},{"Id":411669,"FormularyType":"OHP","DrugName":"ZENATANE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"68001065317"},{"Id":411670,"FormularyType":"OHP","DrugName":"ZENATANE CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"68001065416"},{"Id":411671,"FormularyType":"OHP","DrugName":"ZENATANE CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"68001065417"},{"Id":411672,"FormularyType":"OHP","DrugName":"ZENATANE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"68001065516"},{"Id":411673,"FormularyType":"OHP","DrugName":"ZENATANE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"68001065517"},{"Id":411674,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"68001066006"},{"Id":411675,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"68001066106"},{"Id":411676,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"68001066206"},{"Id":411677,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"68001066304"},{"Id":411678,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"68001066404"},{"Id":411679,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"68001066504"},{"Id":411680,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"68001066601"},{"Id":411681,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"68001066617"},{"Id":411682,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"68001066701"},{"Id":411683,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"68001066719"},{"Id":411684,"FormularyType":"OHP","DrugName":"APREPITANT PAK 125 & 80","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020006320","GenericName":"APREPITANT CAPSULE THERAPY PACK 80 & 125 MG","NDC":"68001066915"},{"Id":411685,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"68001067306"},{"Id":411686,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"68001067492"},{"Id":411687,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68001068400"},{"Id":411688,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68001068403"},{"Id":411689,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68001068500"},{"Id":411690,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68001068503"},{"Id":411691,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68001068600"},{"Id":411692,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68001068603"},{"Id":411693,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"68001068700"},{"Id":411694,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"68001069000"},{"Id":411695,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"68001069100"},{"Id":411696,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"68001069200"},{"Id":411697,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"68016023400"},{"Id":411698,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"68016023700"},{"Id":411699,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"68016029728"},{"Id":411700,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"68016030728"},{"Id":411701,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"68016031000"},{"Id":411702,"FormularyType":"OHP","DrugName":"UNIFINE PNTP MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"68016090728"},{"Id":411703,"FormularyType":"OHP","DrugName":"OB COMPLETE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512010000352","GenericName":"*PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1.25 MG***","NDC":"68025001010"},{"Id":411704,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"68047070201"},{"Id":411705,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100302","GenericName":"DOXYCYCLINE HYCLATE TAB 20 MG","NDC":"68047071401"},{"Id":411706,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100302","GenericName":"DOXYCYCLINE HYCLATE TAB 20 MG","NDC":"68047071460"},{"Id":411707,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"68084015701"},{"Id":411708,"FormularyType":"OHP","DrugName":"MORPHINE SUL TAB 15MG ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055100415","GenericName":"MORPHINE SULFATE TAB ER 15 MG","NDC":"68084015711"},{"Id":411709,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020000140","GenericName":"CYCLOSPORINE CAP 100 MG","NDC":"68084092125"},{"Id":411710,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020000140","GenericName":"CYCLOSPORINE CAP 100 MG","NDC":"68084092195"},{"Id":411711,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094003059"},{"Id":411712,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094003062"},{"Id":411713,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"68094004159"},{"Id":411714,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"68094004161"},{"Id":411715,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"68094004162"},{"Id":411716,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"68094008659"},{"Id":411717,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"68094008661"},{"Id":411718,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"68094011661"},{"Id":411719,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 800MG/20","DosageForm":"SUSP - Suspension","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"68094017459"},{"Id":411720,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 800MG/20","DosageForm":"SUSP - Suspension","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"68094017462"},{"Id":411721,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"68094018659"},{"Id":411722,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"68094018661"},{"Id":411723,"FormularyType":"OHP","DrugName":"VITAMIN D3 DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"68094022401"},{"Id":411724,"FormularyType":"OHP","DrugName":"VITAMIN D3 DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"68094022458"},{"Id":411725,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094023101"},{"Id":411726,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094023158"},{"Id":411727,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094023159"},{"Id":411728,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094023161"},{"Id":411729,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"68094023162"},{"Id":411730,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"68094048060"},{"Id":411731,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"68094048070"},{"Id":411732,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68094048950"},{"Id":411733,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68094048960"},{"Id":411734,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"68094058060"},{"Id":411735,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"68094058070"},{"Id":411736,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68094058950"},{"Id":411737,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68094058960"},{"Id":411738,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"68094060059"},{"Id":411739,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"68094060061"},{"Id":411740,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"68094060062"},{"Id":411741,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"68094068860"},{"Id":411742,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"68094068870"},{"Id":411743,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000340","GenericName":"AZITHROMYCIN TAB 600 MG","NDC":"68094069030"},{"Id":411744,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"68094079903"},{"Id":411745,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"68094079909"},{"Id":411746,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"68094079930"},{"Id":411747,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"68094079950"},{"Id":411748,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"68094080450"},{"Id":411749,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"68094080460"},{"Id":411750,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"68094080510"},{"Id":411751,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"68094080610"},{"Id":411752,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"68094080620"},{"Id":411753,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000305","GenericName":"METHAZOLAMIDE TAB 50 MG","NDC":"68094080850"},{"Id":411754,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"68094090006"},{"Id":411755,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"68094090018"},{"Id":411756,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"68094090030"},{"Id":411757,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"68094090050"},{"Id":411758,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"68094090450"},{"Id":411759,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"68094090460"},{"Id":411760,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"68094090510"},{"Id":411761,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"68094090610"},{"Id":411762,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"68094090620"},{"Id":411763,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000303","GenericName":"METHAZOLAMIDE TAB 25 MG","NDC":"68094090850"},{"Id":411764,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"68094090930"},{"Id":411765,"FormularyType":"OHP","DrugName":"NALTREXONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400030100305","GenericName":"NALTREXONE HCL TAB 50 MG","NDC":"68094090950"},{"Id":411766,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"68134080101"},{"Id":411767,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"68134080103"},{"Id":411768,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"68134080107"},{"Id":411769,"FormularyType":"OHP","DrugName":"VOXZOGO INJ 0.4MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.4","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"NATRIURETIC PEPTIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30950080002120","GenericName":"VOSORITIDE FOR SUBCUTANEOUS INJ 0.4 MG","NDC":"68135008236"},{"Id":411770,"FormularyType":"OHP","DrugName":"VOXZOGO INJ 0.56MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"0.56","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"NATRIURETIC PEPTIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30950080002130","GenericName":"VOSORITIDE FOR SUBCUTANEOUS INJ 0.56 MG","NDC":"68135011966"},{"Id":411771,"FormularyType":"OHP","DrugName":"VOXZOGO INJ 1.2MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.2","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"NATRIURETIC PEPTIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30950080002140","GenericName":"VOSORITIDE FOR SUBCUTANEOUS INJ 1.2 MG","NDC":"68135018193"},{"Id":411772,"FormularyType":"OHP","DrugName":"FIBER THERAP CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"68163011960"},{"Id":411773,"FormularyType":"OHP","DrugName":"ANTACID EXTR CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"68163102208"},{"Id":411774,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"68163103307"},{"Id":411775,"FormularyType":"OHP","DrugName":"FIBER THERAP CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"68163119101"},{"Id":411776,"FormularyType":"OHP","DrugName":"DEKAS PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MULTIPLE VITAMINS W/ MINERALS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78420000000900","GenericName":"*PEDIATRIC MULTIPLE VITAMIN W/ MINERALS LIQUID**","NDC":"68176000010"},{"Id":411777,"FormularyType":"OHP","DrugName":"DEKAS PLUS CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIPLE VITAMINS W/ MINERALS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78310000000100","GenericName":"*MULTIPLE VITAMINS W/ MINERALS CAP**","NDC":"68176000011"},{"Id":411778,"FormularyType":"OHP","DrugName":"DEKAS CAP ESSENTIA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIVITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78200000000100","GenericName":"*MULTIPLE VITAMIN CAP**","NDC":"68176000012"},{"Id":411779,"FormularyType":"OHP","DrugName":"DEKAS LIQ ESSENTIA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIVITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78200000000900","GenericName":"*MULTIPLE VITAMIN LIQUID**","NDC":"68176000013"},{"Id":411780,"FormularyType":"OHP","DrugName":"DEKAS PLUS CAP OCEAN","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIPLE VITAMINS W/ MINERALS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78310000000100","GenericName":"*MULTIPLE VITAMINS W/ MINERALS CAP**","NDC":"68176000014"},{"Id":411781,"FormularyType":"OHP","DrugName":"DEKAS PLUS CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIPLE VITAMINS W/ MINERALS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78310000000500","GenericName":"*MULTIPLE VITAMINS W/ MINERALS CHEW TAB**","NDC":"68176000015"},{"Id":411782,"FormularyType":"OHP","DrugName":"DEKAS CHW BARIATRI","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"MULTIPLE VITAMINS W/ MINERALS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78310000000500","GenericName":"*MULTIPLE VITAMINS W/ MINERALS CHEW TAB**","NDC":"68176000016"},{"Id":411783,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"68180011202"},{"Id":411784,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"68180011209"},{"Id":411785,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"68180011216"},{"Id":411786,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"68180011302"},{"Id":411787,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"68180011309"},{"Id":411788,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"68180011316"},{"Id":411789,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"68180011402"},{"Id":411790,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"68180011409"},{"Id":411791,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"68180011416"},{"Id":411792,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"68180011507"},{"Id":411793,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007520","GenericName":"LEVETIRACETAM TAB ER 24HR 500 MG","NDC":"68180011707"},{"Id":411794,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"68180011807"},{"Id":411795,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"68180012101"},{"Id":411796,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000105","GenericName":"CEPHALEXIN CAP 250 MG","NDC":"68180012102"},{"Id":411797,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"68180012201"},{"Id":411798,"FormularyType":"OHP","DrugName":"CEPHALEXIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020000110","GenericName":"CEPHALEXIN CAP 500 MG","NDC":"68180012202"},{"Id":411799,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 43MG","DosageForm":"CAPS - Capsule","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100104","GenericName":"FENOFIBRATE MICRONIZED CAP 43 MG","NDC":"68180013006"},{"Id":411800,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"68180015001"},{"Id":411801,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007520","GenericName":"MIRABEGRON TAB ER 24 HR 25 MG","NDC":"68180015106"},{"Id":411802,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007520","GenericName":"MIRABEGRON TAB ER 24 HR 25 MG","NDC":"68180015109"},{"Id":411803,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007530","GenericName":"MIRABEGRON TAB ER 24 HR 50 MG","NDC":"68180015206"},{"Id":411804,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007530","GenericName":"MIRABEGRON TAB ER 24 HR 50 MG","NDC":"68180015209"},{"Id":411805,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"68180015701"},{"Id":411806,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"68180015801"},{"Id":411807,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"68180018001"},{"Id":411808,"FormularyType":"OHP","DrugName":"CEFADROXIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010000105","GenericName":"CEFADROXIL CAP 500 MG","NDC":"68180018008"},{"Id":411809,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001910","GenericName":"CEFADROXIL FOR SUSP 250 MG/5ML","NDC":"68180018102"},{"Id":411810,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"68180018202"},{"Id":411811,"FormularyType":"OHP","DrugName":"CEFADROXIL SUS 500/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100010001915","GenericName":"CEFADROXIL FOR SUSP 500 MG/5ML","NDC":"68180018203"},{"Id":411812,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"68180021506"},{"Id":411813,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 50-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450320","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","NDC":"68180021509"},{"Id":411814,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"68180021606"},{"Id":411815,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450325","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","NDC":"68180021609"},{"Id":411816,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"68180021706"},{"Id":411817,"FormularyType":"OHP","DrugName":"LOSARTAN/HCT TAB 100-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002450340","GenericName":"LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","NDC":"68180021709"},{"Id":411818,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"68180022907"},{"Id":411819,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"68180023007"},{"Id":411820,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"68180023109"},{"Id":411821,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"68180023301"},{"Id":411822,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"68180023302"},{"Id":411823,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100305","GenericName":"ETHAMBUTOL HCL TAB 100 MG","NDC":"68180028001"},{"Id":411824,"FormularyType":"OHP","DrugName":"ETHAMBUTOL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000040100310","GenericName":"ETHAMBUTOL HCL TAB 400 MG","NDC":"68180028101"},{"Id":411825,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"68180034507"},{"Id":411826,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"68180034606"},{"Id":411827,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"68180037603"},{"Id":411828,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"68180037609"},{"Id":411829,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"68180037703"},{"Id":411830,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"68180037709"},{"Id":411831,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"68180037803"},{"Id":411832,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"68180037809"},{"Id":411833,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"68180038809"},{"Id":411834,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"68180038902"},{"Id":411835,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"68180038909"},{"Id":411836,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"68180039601"},{"Id":411837,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"68180039901"},{"Id":411838,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001910","GenericName":"CEFPROZIL FOR SUSP 125 MG/5ML","NDC":"68180040103"},{"Id":411839,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"68180040201"},{"Id":411840,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"68180040202"},{"Id":411841,"FormularyType":"OHP","DrugName":"CEFPROZIL SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062001920","GenericName":"CEFPROZIL FOR SUSP 250 MG/5ML","NDC":"68180040203"},{"Id":411842,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000320","GenericName":"CEFPROZIL TAB 250 MG","NDC":"68180040301"},{"Id":411843,"FormularyType":"OHP","DrugName":"CEFPROZIL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 2ND GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02200062000330","GenericName":"CEFPROZIL TAB 500 MG","NDC":"68180040401"},{"Id":411844,"FormularyType":"OHP","DrugName":"CEFIXIME SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060001910","GenericName":"CEFIXIME FOR SUSP 100 MG/5ML","NDC":"68180040501"},{"Id":411845,"FormularyType":"OHP","DrugName":"CEFIXIME SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060001920","GenericName":"CEFIXIME FOR SUSP 200 MG/5ML","NDC":"68180040703"},{"Id":411846,"FormularyType":"OHP","DrugName":"CEFIXIME SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060001920","GenericName":"CEFIXIME FOR SUSP 200 MG/5ML","NDC":"68180040704"},{"Id":411847,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"68180042201"},{"Id":411848,"FormularyType":"OHP","DrugName":"CEFIXIME CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060000120","GenericName":"CEFIXIME CAP 400 MG","NDC":"68180042308"},{"Id":411849,"FormularyType":"OHP","DrugName":"CEFIXIME CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300060000120","GenericName":"CEFIXIME CAP 400 MG","NDC":"68180042311"},{"Id":411850,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"68180044001"},{"Id":411851,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001910","GenericName":"CEPHALEXIN FOR SUSP 125 MG/5ML","NDC":"68180044002"},{"Id":411852,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"68180044101"},{"Id":411853,"FormularyType":"OHP","DrugName":"CEPHALEXIN SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100020001915","GenericName":"CEPHALEXIN FOR SUSP 250 MG/5ML","NDC":"68180044102"},{"Id":411854,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"68180045501"},{"Id":411855,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"68180045502"},{"Id":411856,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200140","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","NDC":"68180045901"},{"Id":411857,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200145","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","NDC":"68180046301"},{"Id":411858,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"68180046403"},{"Id":411859,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"68180046406"},{"Id":411860,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"68180046409"},{"Id":411861,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"68180046503"},{"Id":411862,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"68180046506"},{"Id":411863,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"68180046509"},{"Id":411864,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"68180046701"},{"Id":411865,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"68180046703"},{"Id":411866,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"68180046707"},{"Id":411867,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000305","GenericName":"LOVASTATIN TAB 10 MG","NDC":"68180046709"},{"Id":411868,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68180046801"},{"Id":411869,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68180046803"},{"Id":411870,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68180046805"},{"Id":411871,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68180046807"},{"Id":411872,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68180046901"},{"Id":411873,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68180046903"},{"Id":411874,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68180046905"},{"Id":411875,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68180046907"},{"Id":411876,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-20MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200150","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","NDC":"68180047201"},{"Id":411877,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 10-40MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200160","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","NDC":"68180047301"},{"Id":411878,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"68180047801"},{"Id":411879,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"68180047802"},{"Id":411880,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"68180047803"},{"Id":411881,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"68180047901"},{"Id":411882,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"68180047902"},{"Id":411883,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"68180047903"},{"Id":411884,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"68180051201"},{"Id":411885,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"68180051202"},{"Id":411886,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"68180051230"},{"Id":411887,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"68180051301"},{"Id":411888,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"68180051303"},{"Id":411889,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"68180051330"},{"Id":411890,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"68180051801"},{"Id":411891,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"68180051802"},{"Id":411892,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"68180051901"},{"Id":411893,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"68180051902"},{"Id":411894,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"68180052001"},{"Id":411895,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"68180052002"},{"Id":411896,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"68180054502"},{"Id":411897,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM CRE","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902253700","GenericName":"NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","NDC":"68180054503"},{"Id":411898,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"68180058901"},{"Id":411899,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"68180058902"},{"Id":411900,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"68180058909"},{"Id":411901,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"68180058910"},{"Id":411902,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68180059001"},{"Id":411903,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68180059002"},{"Id":411904,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68180059009"},{"Id":411905,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68180059010"},{"Id":411906,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68180059101"},{"Id":411907,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68180059102"},{"Id":411908,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68180059109"},{"Id":411909,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68180059110"},{"Id":411910,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"68180064401"},{"Id":411911,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000105","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 50 MG","NDC":"68180065001"},{"Id":411912,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"68180065208"},{"Id":411913,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000105","GenericName":"RIFAMPIN CAP 150 MG","NDC":"68180065806"},{"Id":411914,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"68180065906"},{"Id":411915,"FormularyType":"OHP","DrugName":"RIFAMPIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000080000110","GenericName":"RIFAMPIN CAP 300 MG","NDC":"68180065907"},{"Id":411916,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"68180067511"},{"Id":411917,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"68180067611"},{"Id":411918,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"68180067711"},{"Id":411919,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"68180067801"},{"Id":411920,"FormularyType":"OHP","DrugName":"CEFDINIR CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040000120","GenericName":"CEFDINIR CAP 300 MG","NDC":"68180071160"},{"Id":411921,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68180072103"},{"Id":411922,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68180072109"},{"Id":411923,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"68180072204"},{"Id":411924,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 125/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001920","GenericName":"CEFDINIR FOR SUSP 125 MG/5ML","NDC":"68180072205"},{"Id":411925,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"68180072304"},{"Id":411926,"FormularyType":"OHP","DrugName":"CEFDINIR SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300040001930","GenericName":"CEFDINIR FOR SUSP 250 MG/5ML","NDC":"68180072305"},{"Id":411927,"FormularyType":"OHP","DrugName":"ENSKYCE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68180073971"},{"Id":411928,"FormularyType":"OHP","DrugName":"ENSKYCE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68180073973"},{"Id":411929,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 2.5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200120","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","NDC":"68180075501"},{"Id":411930,"FormularyType":"OHP","DrugName":"AMLOD/BENAZP CAP 5-10MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991502200130","GenericName":"AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","NDC":"68180075601"},{"Id":411931,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"68180079901"},{"Id":411932,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"68180079902"},{"Id":411933,"FormularyType":"OHP","DrugName":"LAPATINIB TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533026100320","GenericName":"LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV)","NDC":"68180080136"},{"Id":411934,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"68180081942"},{"Id":411935,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"68180081952"},{"Id":411936,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"68180082046"},{"Id":411937,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"68180082053"},{"Id":411938,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"68180082110"},{"Id":411939,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"68180082147"},{"Id":411940,"FormularyType":"OHP","DrugName":"TRI-LO- TAB MARZIA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"68180083771"},{"Id":411941,"FormularyType":"OHP","DrugName":"TRI-LO- TAB MARZIA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"68180083773"},{"Id":411942,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"68180083871"},{"Id":411943,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"68180083873"},{"Id":411944,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"68180084071"},{"Id":411945,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"68180084073"},{"Id":411946,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"68180084311"},{"Id":411947,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"68180084313"},{"Id":411948,"FormularyType":"OHP","DrugName":"KURVELO TAB 0.15/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68180084471"},{"Id":411949,"FormularyType":"OHP","DrugName":"KURVELO TAB 0.15/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68180084473"},{"Id":411950,"FormularyType":"OHP","DrugName":"DAYSEE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"68180084611"},{"Id":411951,"FormularyType":"OHP","DrugName":"DAYSEE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"68180084613"},{"Id":411952,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"68180084811"},{"Id":411953,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"68180084813"},{"Id":411954,"FormularyType":"OHP","DrugName":"MY WAY TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"68180085211"},{"Id":411955,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"68180085471"},{"Id":411956,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB 0.1-0.02","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"68180085473"},{"Id":411957,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002100310","GenericName":"LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","NDC":"68180085771"},{"Id":411958,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002100310","GenericName":"LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","NDC":"68180085773"},{"Id":411959,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"68180086106"},{"Id":411960,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"68180086111"},{"Id":411961,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"68180086206"},{"Id":411962,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"68180086211"},{"Id":411963,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000340","GenericName":"AZITHROMYCIN TAB 600 MG","NDC":"68180086306"},{"Id":411964,"FormularyType":"OHP","DrugName":"BLISOVI 24 TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"68180086471"},{"Id":411965,"FormularyType":"OHP","DrugName":"BLISOVI 24 TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"68180086473"},{"Id":411966,"FormularyType":"OHP","DrugName":"BLISOVI FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"68180086571"},{"Id":411967,"FormularyType":"OHP","DrugName":"BLISOVI FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"68180086573"},{"Id":411968,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"68180086871"},{"Id":411969,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"68180086873"},{"Id":411970,"FormularyType":"OHP","DrugName":"BLISOVI FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"68180086911"},{"Id":411971,"FormularyType":"OHP","DrugName":"BLISOVI FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"68180086913"},{"Id":411972,"FormularyType":"OHP","DrugName":"WYMZYA FE CHW 0.4MG-35","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600520","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","NDC":"68180087371"},{"Id":411973,"FormularyType":"OHP","DrugName":"WYMZYA FE CHW 0.4MG-35","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600520","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","NDC":"68180087373"},{"Id":411974,"FormularyType":"OHP","DrugName":"VYFEMLA TAB 0.4-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"68180087571"},{"Id":411975,"FormularyType":"OHP","DrugName":"VYFEMLA TAB 0.4-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"68180087573"},{"Id":411976,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68180087671"},{"Id":411977,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68180087673"},{"Id":411978,"FormularyType":"OHP","DrugName":"JENCYCLA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68180087771"},{"Id":411979,"FormularyType":"OHP","DrugName":"JENCYCLA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68180087773"},{"Id":411980,"FormularyType":"OHP","DrugName":"NIKKI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"68180088671"},{"Id":411981,"FormularyType":"OHP","DrugName":"NIKKI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"68180088673"},{"Id":411982,"FormularyType":"OHP","DrugName":"ENSKYCE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68180089171"},{"Id":411983,"FormularyType":"OHP","DrugName":"ENSKYCE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68180089173"},{"Id":411984,"FormularyType":"OHP","DrugName":"DROS/ETH EST TAB LEVOMEFO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200320","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG","NDC":"68180089471"},{"Id":411985,"FormularyType":"OHP","DrugName":"DROS/ETH EST TAB LEVOMEFO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200320","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG","NDC":"68180089473"},{"Id":411986,"FormularyType":"OHP","DrugName":"TURQOZ TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002900310","GenericName":"NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","NDC":"68180089513"},{"Id":411987,"FormularyType":"OHP","DrugName":"KAITLIB FE CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600540","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG","NDC":"68180090371"},{"Id":411988,"FormularyType":"OHP","DrugName":"KAITLIB FE CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600540","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG","NDC":"68180090373"},{"Id":411989,"FormularyType":"OHP","DrugName":"TYDEMY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200330","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG","NDC":"68180090471"},{"Id":411990,"FormularyType":"OHP","DrugName":"TYDEMY TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003200330","GenericName":"DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG","NDC":"68180090473"},{"Id":411991,"FormularyType":"OHP","DrugName":"MIBELAS 24 CHW FE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"68180091171"},{"Id":411992,"FormularyType":"OHP","DrugName":"MIBELAS 24 CHW FE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"68180091173"},{"Id":411993,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"68180094111"},{"Id":411994,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"68180095001"},{"Id":411995,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"68180095002"},{"Id":411996,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"68180095004"},{"Id":411997,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"68180095601"},{"Id":411998,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"68180095602"},{"Id":411999,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"68180095603"},{"Id":412000,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"68180095604"},{"Id":412001,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"68180096204"},{"Id":412002,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"68180096256"},{"Id":412003,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"68180096301"},{"Id":412004,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"68180096501"},{"Id":412005,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"68180096503"},{"Id":412006,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"68180096509"},{"Id":412007,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"68180096601"},{"Id":412008,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"68180096603"},{"Id":412009,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"68180096609"},{"Id":412010,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"68180096701"},{"Id":412011,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"68180096703"},{"Id":412012,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"68180096709"},{"Id":412013,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"68180096801"},{"Id":412014,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"68180096803"},{"Id":412015,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"68180096809"},{"Id":412016,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"68180096901"},{"Id":412017,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"68180096903"},{"Id":412018,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"68180096909"},{"Id":412019,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"68180097001"},{"Id":412020,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"68180097003"},{"Id":412021,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"68180097009"},{"Id":412022,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"68180097101"},{"Id":412023,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"68180097103"},{"Id":412024,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"68180097109"},{"Id":412025,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"68180097201"},{"Id":412026,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"68180097203"},{"Id":412027,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"68180097209"},{"Id":412028,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"68180097301"},{"Id":412029,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"68180097303"},{"Id":412030,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"68180097309"},{"Id":412031,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"68180097401"},{"Id":412032,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"68180097403"},{"Id":412033,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"68180097409"},{"Id":412034,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"68180097501"},{"Id":412035,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"68180097503"},{"Id":412036,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"68180097509"},{"Id":412037,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"68180097601"},{"Id":412038,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"68180097603"},{"Id":412039,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"68180097609"},{"Id":412040,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"68180097901"},{"Id":412041,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"68180097903"},{"Id":412042,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"68180097930"},{"Id":412043,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"68180098001"},{"Id":412044,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"68180098003"},{"Id":412045,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"68180098030"},{"Id":412046,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"68180098101"},{"Id":412047,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"68180098103"},{"Id":412048,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"68180098130"},{"Id":412049,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"68180098201"},{"Id":412050,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"68180098202"},{"Id":412051,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"68180098230"},{"Id":412052,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"68180098405"},{"Id":412053,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"68180098430"},{"Id":412054,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"68196010750"},{"Id":412055,"FormularyType":"OHP","DrugName":"MM ACID-PEP TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"68196012100"},{"Id":412056,"FormularyType":"OHP","DrugName":"MM ACETAMINO TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"68196017761"},{"Id":412057,"FormularyType":"OHP","DrugName":"MM CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"68196030607"},{"Id":412058,"FormularyType":"OHP","DrugName":"MM ACETAMINO TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"68196031060"},{"Id":412059,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"68196085360"},{"Id":412060,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"68196087005"},{"Id":412061,"FormularyType":"OHP","DrugName":"MM ASPIRIN TAB LOW DOSE","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"68196090196"},{"Id":412062,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"68196099860"},{"Id":412063,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"68196301601"},{"Id":412064,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"68196303601"},{"Id":412065,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1/2ML/30","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"68196305601"},{"Id":412066,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"68196311601"},{"Id":412067,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3ML/31","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"68196313601"},{"Id":412068,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1/2ML/31","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"68196315601"},{"Id":412069,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"68196893001"},{"Id":412070,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"68196893101"},{"Id":412071,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"68196893201"},{"Id":412072,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"68196893301"},{"Id":412073,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"68210130004"},{"Id":412074,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"68308057001"},{"Id":412075,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"68308057030"},{"Id":412076,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"68308057101"},{"Id":412077,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"68308057130"},{"Id":412078,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"68308057301"},{"Id":412079,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"68308057330"},{"Id":412080,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"68308057501"},{"Id":412081,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"68308057530"},{"Id":412082,"FormularyType":"OHP","DrugName":"METRONIDAZOL CRE 0.75%","DosageForm":"CREA - Cream","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040003710","GenericName":"METRONIDAZOLE CREAM 0.75%","NDC":"68308071145"},{"Id":412083,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"68308078101"},{"Id":412084,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"68308078130"},{"Id":412085,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"68308078201"},{"Id":412086,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"68308078230"},{"Id":412087,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"68308078301"},{"Id":412088,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"68308078330"},{"Id":412089,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"68308078401"},{"Id":412090,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"68308078430"},{"Id":412091,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"68382000301"},{"Id":412092,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"68382000305"},{"Id":412093,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006820","GenericName":"TOPIRAMATE SPRINKLE CAP 15 MG","NDC":"68382000414"},{"Id":412094,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 25MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006830","GenericName":"TOPIRAMATE SPRINKLE CAP 25 MG","NDC":"68382000514"},{"Id":412095,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"68382002201"},{"Id":412096,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"68382002210"},{"Id":412097,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"68382002301"},{"Id":412098,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"68382002310"},{"Id":412099,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"68382002401"},{"Id":412100,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"68382002410"},{"Id":412101,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100305","GenericName":"PROMETHAZINE HCL TAB 12.5 MG","NDC":"68382004001"},{"Id":412102,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"68382004101"},{"Id":412103,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"68382004105"},{"Id":412104,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100310","GenericName":"PROMETHAZINE HCL TAB 25 MG","NDC":"68382004110"},{"Id":412105,"FormularyType":"OHP","DrugName":"PROMETHAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020100315","GenericName":"PROMETHAZINE HCL TAB 50 MG","NDC":"68382004201"},{"Id":412106,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"68382005001"},{"Id":412107,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"68382005005"},{"Id":412108,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"68382005101"},{"Id":412109,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"68382005105"},{"Id":412110,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"68382009101"},{"Id":412111,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"68382009201"},{"Id":412112,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"68382009205"},{"Id":412113,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"68382009301"},{"Id":412114,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"68382009305"},{"Id":412115,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"68382009401"},{"Id":412116,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"68382009405"},{"Id":412117,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"68382009501"},{"Id":412118,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"68382009505"},{"Id":412119,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"68382009601"},{"Id":412120,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"68382009605"},{"Id":412121,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100105","GenericName":"BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT)","NDC":"68382011006"},{"Id":412122,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"68382012105"},{"Id":412123,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"68382012116"},{"Id":412124,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"68382012205"},{"Id":412125,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"68382012216"},{"Id":412126,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68382012305"},{"Id":412127,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68382012316"},{"Id":412128,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"68382013201"},{"Id":412129,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"68382013210"},{"Id":412130,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"68382013216"},{"Id":412131,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"68382013506"},{"Id":412132,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"68382013510"},{"Id":412133,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"68382013516"},{"Id":412134,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"68382013606"},{"Id":412135,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"68382013610"},{"Id":412136,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"68382013616"},{"Id":412137,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"68382013706"},{"Id":412138,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"68382013710"},{"Id":412139,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"68382013716"},{"Id":412140,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"68382013805"},{"Id":412141,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"68382013814"},{"Id":412142,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"68382013905"},{"Id":412143,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"68382013914"},{"Id":412144,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"68382014005"},{"Id":412145,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"68382014014"},{"Id":412146,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"68382014105"},{"Id":412147,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"68382014114"},{"Id":412148,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"68382014406"},{"Id":412149,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"68382014501"},{"Id":412150,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"68382014601"},{"Id":412151,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"68382014701"},{"Id":412152,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-250M","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350320","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG","NDC":"68382018401"},{"Id":412153,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 2.5-500M","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350325","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG","NDC":"68382018501"},{"Id":412154,"FormularyType":"OHP","DrugName":"GLIP/METFORM TAB 5-500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"ANTIDIABETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27997002350340","GenericName":"GLIPIZIDE-METFORMIN HCL TAB 5-500 MG","NDC":"68382018601"},{"Id":412155,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68382020401"},{"Id":412156,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68382020405"},{"Id":412157,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68382020501"},{"Id":412158,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68382020505"},{"Id":412159,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"68382020906"},{"Id":412160,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"68382022705"},{"Id":412161,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"68382022714"},{"Id":412162,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"68382024701"},{"Id":412163,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"68382024705"},{"Id":412164,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"68382024910"},{"Id":412165,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"68382024916"},{"Id":412166,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"68382025010"},{"Id":412167,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"68382025016"},{"Id":412168,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"68382025110"},{"Id":412169,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"68382025116"},{"Id":412170,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"68382025210"},{"Id":412171,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"68382025216"},{"Id":412172,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"68382025501"},{"Id":412173,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"68382025505"},{"Id":412174,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"68382025601"},{"Id":412175,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"68382025605"},{"Id":412176,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"68382025701"},{"Id":412177,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100105","GenericName":"MINOCYCLINE HCL CAP 50 MG","NDC":"68382031601"},{"Id":412178,"FormularyType":"OHP","DrugName":"MINOCYCLINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000040100110","GenericName":"MINOCYCLINE HCL CAP 100 MG","NDC":"68382031818"},{"Id":412179,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"68382035101"},{"Id":412180,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000330","GenericName":"SIROLIMUS TAB 2 MG","NDC":"68382035201"},{"Id":412181,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"68382037001"},{"Id":412182,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"68382037002"},{"Id":412183,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"68382037003"},{"Id":412184,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"68382038306"},{"Id":412185,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"68382041101"},{"Id":412186,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"68382041201"},{"Id":412187,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"68382041205"},{"Id":412188,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 800MG DR","DosageForm":"TBEC - Tablet DR","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000650","GenericName":"MESALAMINE TAB DELAYED RELEASE 800 MG","NDC":"68382043528"},{"Id":412189,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"68382044106"},{"Id":412190,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"68382044110"},{"Id":412191,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"68382044116"},{"Id":412192,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"68382044206"},{"Id":412193,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"68382044210"},{"Id":412194,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"68382044216"},{"Id":412195,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"68382044405"},{"Id":412196,"FormularyType":"OHP","DrugName":"MESALAMINE CAP 0.375GM","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0.375","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030007020","GenericName":"MESALAMINE CAP ER 24HR 0.375 GM","NDC":"68382045219"},{"Id":412197,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"68382047130"},{"Id":412198,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"68382047178"},{"Id":412199,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"68382047230"},{"Id":412200,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"68382047278"},{"Id":412201,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"68382047330"},{"Id":412202,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"68382047378"},{"Id":412203,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 50MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006840","GenericName":"TOPIRAMATE SPRINKLE CAP 50 MG","NDC":"68382049814"},{"Id":412204,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68382050001"},{"Id":412205,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68382050005"},{"Id":412206,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68382050010"},{"Id":412207,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"68382051201"},{"Id":412208,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"68382051205"},{"Id":412209,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000310","GenericName":"SIROLIMUS TAB 0.5 MG","NDC":"68382052001"},{"Id":412210,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"68382052501"},{"Id":412211,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"68382052601"},{"Id":412212,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"68382052605"},{"Id":412213,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"68382052701"},{"Id":412214,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"68382052705"},{"Id":412215,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010002905","GenericName":"CHOLESTYRAMINE POWDER 4 GM/DOSE","NDC":"68382052842"},{"Id":412216,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010003005","GenericName":"CHOLESTYRAMINE POWDER PACKETS 4 GM","NDC":"68382052860"},{"Id":412217,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"POWD - Powder","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010102905","GenericName":"CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","NDC":"68382052942"},{"Id":412218,"FormularyType":"OHP","DrugName":"CHOLESTYRAM POW 4GM LITE","DosageForm":"PACK - Packet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100010103005","GenericName":"CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","NDC":"68382052960"},{"Id":412219,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"68382053601"},{"Id":412220,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"68382053701"},{"Id":412221,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"68382053801"},{"Id":412222,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007410","GenericName":"CARBAMAZEPINE TAB ER 12HR 100 MG","NDC":"68382055501"},{"Id":412223,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007420","GenericName":"CARBAMAZEPINE TAB ER 12HR 200 MG","NDC":"68382055601"},{"Id":412224,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 400MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020007440","GenericName":"CARBAMAZEPINE TAB ER 12HR 400 MG","NDC":"68382055701"},{"Id":412225,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"68382055901"},{"Id":412226,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68382056401"},{"Id":412227,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"68382056410"},{"Id":412228,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68382056501"},{"Id":412229,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"68382056510"},{"Id":412230,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68382056601"},{"Id":412231,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68382056610"},{"Id":412232,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"68382056701"},{"Id":412233,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"68382056705"},{"Id":412234,"FormularyType":"OHP","DrugName":"ACAMPRO CAL TAB 333MG","DosageForm":"TBEC - Tablet DR","Strength":"333","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802010200620","GenericName":"ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","NDC":"68382056928"},{"Id":412235,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"68382058201"},{"Id":412236,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"68382058301"},{"Id":412237,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"68382058401"},{"Id":412238,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"68382059505"},{"Id":412239,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"68382059516"},{"Id":412240,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"68382059605"},{"Id":412241,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"68382059616"},{"Id":412242,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"68382059705"},{"Id":412243,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"68382059716"},{"Id":412244,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"68382059805"},{"Id":412245,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"68382059816"},{"Id":412246,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127060","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","NDC":"68382059916"},{"Id":412247,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"68382062430"},{"Id":412248,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"68382062431"},{"Id":412249,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"68382062483"},{"Id":412250,"FormularyType":"OHP","DrugName":"PYRIDOSTIGM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"76000050100305","GenericName":"PYRIDOSTIGMINE BROMIDE TAB 60 MG","NDC":"68382065906"},{"Id":412251,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"68382066001"},{"Id":412252,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"68382066005"},{"Id":412253,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"68382066010"},{"Id":412254,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"68382066101"},{"Id":412255,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"68382066105"},{"Id":412256,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"68382066201"},{"Id":412257,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"68382066205"},{"Id":412258,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000110","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 100 MG","NDC":"68382070718"},{"Id":412259,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"68382071119"},{"Id":412260,"FormularyType":"OHP","DrugName":"BUDESONIDE CAP 3MG DR","DosageForm":"CPEP - Capsule DR Part","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100012006720","GenericName":"BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","NDC":"68382072001"},{"Id":412261,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"68382072116"},{"Id":412262,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"68382072216"},{"Id":412263,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"68382073201"},{"Id":412264,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"68382073301"},{"Id":412265,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"68382073401"},{"Id":412266,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"68382073701"},{"Id":412267,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"68382073801"},{"Id":412268,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"68382073901"},{"Id":412269,"FormularyType":"OHP","DrugName":"TIADYLT CAP 120MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117020","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG","NDC":"68382074516"},{"Id":412270,"FormularyType":"OHP","DrugName":"TIADYLT CAP 180MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117030","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","NDC":"68382074616"},{"Id":412271,"FormularyType":"OHP","DrugName":"TIADYLT CAP 240MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117040","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","NDC":"68382074716"},{"Id":412272,"FormularyType":"OHP","DrugName":"TIADYLT CAP 300MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117050","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","NDC":"68382074816"},{"Id":412273,"FormularyType":"OHP","DrugName":"TIADYLT CAP 360MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117060","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","NDC":"68382074916"},{"Id":412274,"FormularyType":"OHP","DrugName":"TIADYLT CAP 420MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117070","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 420 MG","NDC":"68382075016"},{"Id":412275,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"68382075801"},{"Id":412276,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"68382075805"},{"Id":412277,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"68382075810"},{"Id":412278,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"68382075901"},{"Id":412279,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"68382075905"},{"Id":412280,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"68382075910"},{"Id":412281,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"68382076001"},{"Id":412282,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"68382076005"},{"Id":412283,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"68382076010"},{"Id":412284,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"68382077305"},{"Id":412285,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"68382077306"},{"Id":412286,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"68382077316"},{"Id":412287,"FormularyType":"OHP","DrugName":"METHOTREXATE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300050100310","GenericName":"METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","NDC":"68382077501"},{"Id":412288,"FormularyType":"OHP","DrugName":"DOXYCYC MONO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000105","GenericName":"DOXYCYCLINE MONOHYDRATE CAP 50 MG","NDC":"68382078201"},{"Id":412289,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"68382078301"},{"Id":412290,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100310","GenericName":"DOXAZOSIN MESYLATE TAB 1 MG","NDC":"68382078310"},{"Id":412291,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"68382078401"},{"Id":412292,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100320","GenericName":"DOXAZOSIN MESYLATE TAB 2 MG","NDC":"68382078410"},{"Id":412293,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"68382078501"},{"Id":412294,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100330","GenericName":"DOXAZOSIN MESYLATE TAB 4 MG","NDC":"68382078510"},{"Id":412295,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"68382078601"},{"Id":412296,"FormularyType":"OHP","DrugName":"DOXAZOSIN TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202005100340","GenericName":"DOXAZOSIN MESYLATE TAB 8 MG","NDC":"68382078610"},{"Id":412297,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"68382079101"},{"Id":412298,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"68382079105"},{"Id":412299,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"68382079201"},{"Id":412300,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"68382079205"},{"Id":412301,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"68382079801"},{"Id":412302,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"68382079805"},{"Id":412303,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"68382079901"},{"Id":412304,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"68382079905"},{"Id":412305,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"68382080001"},{"Id":412306,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"68382080005"},{"Id":412307,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"68382082427"},{"Id":412308,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"68382085601"},{"Id":412309,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"68382085605"},{"Id":412310,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"68382085701"},{"Id":412311,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"68382085705"},{"Id":412312,"FormularyType":"OHP","DrugName":"BENZTROPINE INJ 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010102005","GenericName":"BENZTROPINE MESYLATE INJ 1 MG/ML","NDC":"68382086010"},{"Id":412313,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"68382091206"},{"Id":412314,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"68382091306"},{"Id":412315,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"68382091406"},{"Id":412316,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"68382091506"},{"Id":412317,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000310","GenericName":"METHYLPREDNISOLONE TAB 4 MG","NDC":"68382091601"},{"Id":412318,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 4MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210003000B705","GenericName":"METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","NDC":"68382091634"},{"Id":412319,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000315","GenericName":"METHYLPREDNISOLONE TAB 8 MG","NDC":"68382091711"},{"Id":412320,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000320","GenericName":"METHYLPREDNISOLONE TAB 16 MG","NDC":"68382091818"},{"Id":412321,"FormularyType":"OHP","DrugName":"METHYLPRED TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030000330","GenericName":"METHYLPREDNISOLONE TAB 32 MG","NDC":"68382091911"},{"Id":412322,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000320","GenericName":"ENTECAVIR TAB 0.5 MG","NDC":"68382092006"},{"Id":412323,"FormularyType":"OHP","DrugName":"ENTECAVIR TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12352030000330","GenericName":"ENTECAVIR TAB 1 MG","NDC":"68382092106"},{"Id":412324,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100320","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","NDC":"68382092286"},{"Id":412325,"FormularyType":"OHP","DrugName":"ELETRIPTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406025100340","GenericName":"ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","NDC":"68382092386"},{"Id":412326,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"68382095001"},{"Id":412327,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"68382095101"},{"Id":412328,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"68382095201"},{"Id":412329,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"68382095301"},{"Id":412330,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"68382095401"},{"Id":412331,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"68382095501"},{"Id":412332,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"68382095601"},{"Id":412333,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"68382096906"},{"Id":412334,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"68382096916"},{"Id":412335,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"68382097001"},{"Id":412336,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"68382097010"},{"Id":412337,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"68382097101"},{"Id":412338,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"68462010130"},{"Id":412339,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"68462010230"},{"Id":412340,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"68462010430"},{"Id":412341,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"68462010530"},{"Id":412342,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"68462010630"},{"Id":412343,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"68462010805"},{"Id":412344,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"68462010810"},{"Id":412345,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"68462010860"},{"Id":412346,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"68462010905"},{"Id":412347,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"68462010910"},{"Id":412348,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"68462010960"},{"Id":412349,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"68462011010"},{"Id":412350,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"68462011060"},{"Id":412351,"FormularyType":"OHP","DrugName":"APREPITANT PAK 125 & 80","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020006320","GenericName":"APREPITANT CAPSULE THERAPY PACK 80 & 125 MG","NDC":"68462011233"},{"Id":412352,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"68462011940"},{"Id":412353,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"68462011944"},{"Id":412354,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68462012601"},{"Id":412355,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"68462012605"},{"Id":412356,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68462012701"},{"Id":412357,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"68462012705"},{"Id":412358,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"68462012801"},{"Id":412359,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"68462012901"},{"Id":412360,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"68462013001"},{"Id":412361,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"68462013005"},{"Id":412362,"FormularyType":"OHP","DrugName":"NORETH/ETHIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"68462013279"},{"Id":412363,"FormularyType":"OHP","DrugName":"NORETH/ETHIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"68462013281"},{"Id":412364,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"68462013508"},{"Id":412365,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"68462013701"},{"Id":412366,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"68462013801"},{"Id":412367,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"68462013901"},{"Id":412368,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100105","GenericName":"CLINDAMYCIN HCL CAP 75 MG","NDC":"68462014201"},{"Id":412369,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"68462014301"},{"Id":412370,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100110","GenericName":"CLINDAMYCIN HCL CAP 150 MG","NDC":"68462014305"},{"Id":412371,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"68462014401"},{"Id":412372,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"68462015305"},{"Id":412373,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"68462015310"},{"Id":412374,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"68462015360"},{"Id":412375,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"68462015713"},{"Id":412376,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"68462015740"},{"Id":412377,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"68462015811"},{"Id":412378,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"68462015813"},{"Id":412379,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"68462016201"},{"Id":412380,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"68462016205"},{"Id":412381,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"68462016301"},{"Id":412382,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"68462016305"},{"Id":412383,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"68462016401"},{"Id":412384,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"68462016405"},{"Id":412385,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"68462016501"},{"Id":412386,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"68462016505"},{"Id":412387,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"68462016630"},{"Id":412388,"FormularyType":"OHP","DrugName":"MUPIROCIN OIN 2%","DosageForm":"OINT - Ointment","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100065104210","GenericName":"MUPIROCIN OINT 2%","NDC":"68462018022"},{"Id":412389,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"68462018117"},{"Id":412390,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"68462018135"},{"Id":412391,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"68462018147"},{"Id":412392,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"68462018449"},{"Id":412393,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"68462018801"},{"Id":412394,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"68462018805"},{"Id":412395,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"68462018901"},{"Id":412396,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"68462018905"},{"Id":412397,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"68462019001"},{"Id":412398,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"68462019005"},{"Id":412399,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"68462019030"},{"Id":412400,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"68462019050"},{"Id":412401,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"68462019911"},{"Id":412402,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"68462019913"},{"Id":412403,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"68462019930"},{"Id":412404,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"68462019990"},{"Id":412405,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"68462020011"},{"Id":412406,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"68462020013"},{"Id":412407,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"68462020030"},{"Id":412408,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"68462020090"},{"Id":412409,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"68462020111"},{"Id":412410,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"68462020113"},{"Id":412411,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"68462020130"},{"Id":412412,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"68462020190"},{"Id":412413,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 15MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006820","GenericName":"TOPIRAMATE SPRINKLE CAP 15 MG","NDC":"68462021860"},{"Id":412414,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 25MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006830","GenericName":"TOPIRAMATE SPRINKLE CAP 25 MG","NDC":"68462021960"},{"Id":412415,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"68462022690"},{"Id":412416,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"68462023301"},{"Id":412417,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"68462023401"},{"Id":412418,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"68462023501"},{"Id":412419,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"68462025301"},{"Id":412420,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"68462025401"},{"Id":412421,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"68462025501"},{"Id":412422,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"68462025601"},{"Id":412423,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100337","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 3 MG","NDC":"68462025701"},{"Id":412424,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100344","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 4 MG","NDC":"68462025801"},{"Id":412425,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100350","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 5 MG","NDC":"68462025901"},{"Id":412426,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 240MG ER","DosageForm":"TBCR - Tablet ER","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100420","GenericName":"VERAPAMIL HCL TAB ER 240 MG","NDC":"68462026001"},{"Id":412427,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 240MG ER","DosageForm":"TBCR - Tablet ER","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100420","GenericName":"VERAPAMIL HCL TAB ER 240 MG","NDC":"68462026005"},{"Id":412428,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"68462026110"},{"Id":412429,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"68462026190"},{"Id":412430,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"68462026210"},{"Id":412431,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"68462026290"},{"Id":412432,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"68462026310"},{"Id":412433,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"68462026390"},{"Id":412434,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"68462026405"},{"Id":412435,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"68462026430"},{"Id":412436,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG ER","DosageForm":"TBCR - Tablet ER","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100410","GenericName":"VERAPAMIL HCL TAB ER 120 MG","NDC":"68462029201"},{"Id":412437,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 180MG ER","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100415","GenericName":"VERAPAMIL HCL TAB ER 180 MG","NDC":"68462029301"},{"Id":412438,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 180MG ER","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100415","GenericName":"VERAPAMIL HCL TAB ER 180 MG","NDC":"68462029305"},{"Id":412439,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"68462029717"},{"Id":412440,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"68462029735"},{"Id":412441,"FormularyType":"OHP","DrugName":"CICLOPIROX CRE 0.77%","DosageForm":"CREA - Cream","Strength":"0.77","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150030103705","GenericName":"CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","NDC":"68462029792"},{"Id":412442,"FormularyType":"OHP","DrugName":"ADAPAL/BEN P GEL 0.1-2.5%","DosageForm":"GEL - Gel","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90059902034020","GenericName":"ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5%","NDC":"68462030147"},{"Id":412443,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000110","GenericName":"INDOMETHACIN CAP 50 MG","NDC":"68462030201"},{"Id":412444,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000110","GenericName":"INDOMETHACIN CAP 50 MG","NDC":"68462030205"},{"Id":412445,"FormularyType":"OHP","DrugName":"HEATHER TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68462030329"},{"Id":412446,"FormularyType":"OHP","DrugName":"HEATHER TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68462030384"},{"Id":412447,"FormularyType":"OHP","DrugName":"NORETHIN ACE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000030100305","GenericName":"NORETHINDRONE ACETATE TAB 5 MG","NDC":"68462030450"},{"Id":412448,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68462030529"},{"Id":412449,"FormularyType":"OHP","DrugName":"NORETHINDRON TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"68462030584"},{"Id":412450,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"68462030929"},{"Id":412451,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB 0.25/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"68462030984"},{"Id":412452,"FormularyType":"OHP","DrugName":"BRIELLYN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"68462031629"},{"Id":412453,"FormularyType":"OHP","DrugName":"BRIELLYN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500305","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","NDC":"68462031684"},{"Id":412454,"FormularyType":"OHP","DrugName":"VIORELE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"68462031829"},{"Id":412455,"FormularyType":"OHP","DrugName":"VIORELE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"68462031884"},{"Id":412456,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"68462031960"},{"Id":412457,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"68462032060"},{"Id":412458,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"68462032501"},{"Id":412459,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"68462032560"},{"Id":412460,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 75MG ER","DosageForm":"CPCR - Capsule ER","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000205","GenericName":"INDOMETHACIN CAP ER 75 MG","NDC":"68462032590"},{"Id":412461,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100305","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","NDC":"68462033090"},{"Id":412462,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100310","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","NDC":"68462033190"},{"Id":412463,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100315","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","NDC":"68462033290"},{"Id":412464,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100320","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","NDC":"68462033390"},{"Id":412465,"FormularyType":"OHP","DrugName":"PRAMIPEXOLE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203060100330","GenericName":"PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","NDC":"68462033490"},{"Id":412466,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 600MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007560","GenericName":"THEOPHYLLINE TAB ER 24HR 600 MG","NDC":"68462035601"},{"Id":412467,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 400MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007540","GenericName":"THEOPHYLLINE TAB ER 24HR 400 MG","NDC":"68462038001"},{"Id":412468,"FormularyType":"OHP","DrugName":"RILUZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74503070000320","GenericName":"RILUZOLE TAB 50 MG","NDC":"68462038160"},{"Id":412469,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"68462038201"},{"Id":412470,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"68462038301"},{"Id":412471,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"68462038401"},{"Id":412472,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"68462038630"},{"Id":412473,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"68462038690"},{"Id":412474,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"68462038730"},{"Id":412475,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"68462038790"},{"Id":412476,"FormularyType":"OHP","DrugName":"MARLISSA TAB 0.15/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68462038829"},{"Id":412477,"FormularyType":"OHP","DrugName":"MARLISSA TAB 0.15/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"68462038884"},{"Id":412478,"FormularyType":"OHP","DrugName":"ALYACEN TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"68462039429"},{"Id":412479,"FormularyType":"OHP","DrugName":"ALYACEN TAB 1/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500320","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"68462039484"},{"Id":412480,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"68462039501"},{"Id":412481,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 10MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006510","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 10 MG","NDC":"68462039530"},{"Id":412482,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"68462039601"},{"Id":412483,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"68462039610"},{"Id":412484,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"68462039630"},{"Id":412485,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"68462039690"},{"Id":412486,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68462039701"},{"Id":412487,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68462039710"},{"Id":412488,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68462039730"},{"Id":412489,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"68462039790"},{"Id":412490,"FormularyType":"OHP","DrugName":"ASA/DIPYRIDA CAP 25-200MG","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85159902206920","GenericName":"ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","NDC":"68462040560"},{"Id":412491,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"68462040601"},{"Id":412492,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"68462040610"},{"Id":412493,"FormularyType":"OHP","DrugName":"HAILEY FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"68462041929"},{"Id":412494,"FormularyType":"OHP","DrugName":"HAILEY FE TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"68462041984"},{"Id":412495,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"68462042105"},{"Id":412496,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"68462042121"},{"Id":412497,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"68462042169"},{"Id":412498,"FormularyType":"OHP","DrugName":"ACAMPRO CAL TAB 333MG","DosageForm":"TBEC - Tablet DR","Strength":"333","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802010200620","GenericName":"ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","NDC":"68462043518"},{"Id":412499,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"68462043630"},{"Id":412500,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"68462043690"},{"Id":412501,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"68462043730"},{"Id":412502,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"68462043790"},{"Id":412503,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"68462043830"},{"Id":412504,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"68462043890"},{"Id":412505,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100320","GenericName":"SEVELAMER HCL TAB 400 MG","NDC":"68462044626"},{"Id":412506,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100340","GenericName":"SEVELAMER HCL TAB 800 MG","NDC":"68462044718"},{"Id":412507,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"68462046110"},{"Id":412508,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"68462046160"},{"Id":412509,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"68462046940"},{"Id":412510,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"68462046954"},{"Id":412511,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"68462047040"},{"Id":412512,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"68462047054"},{"Id":412513,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"68462047101"},{"Id":412514,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"68462047201"},{"Id":412515,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"68462047205"},{"Id":412516,"FormularyType":"OHP","DrugName":"URSODIOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000325","GenericName":"URSODIOL TAB 250 MG","NDC":"68462047301"},{"Id":412517,"FormularyType":"OHP","DrugName":"URSODIOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000350","GenericName":"URSODIOL TAB 500 MG","NDC":"68462047401"},{"Id":412518,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"68462047720"},{"Id":412519,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"68462047774"},{"Id":412520,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"68462047830"},{"Id":412521,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102121","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.25 GM (BASE EQUIVALENT)","NDC":"68462047884"},{"Id":412522,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"68462047930"},{"Id":412523,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102122","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1.5 GM (BASE EQUIVALENT)","NDC":"68462047984"},{"Id":412524,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"68462049776"},{"Id":412525,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"68462049833"},{"Id":412526,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN CRE 0.005%","DosageForm":"CREA - Cream","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025003710","GenericName":"CALCIPOTRIENE CREAM 0.005%","NDC":"68462050165"},{"Id":412527,"FormularyType":"OHP","DrugName":"CALCIPOTRIEN CRE 0.005%","DosageForm":"CREA - Cream","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250025003710","GenericName":"CALCIPOTRIENE CREAM 0.005%","NDC":"68462050166"},{"Id":412528,"FormularyType":"OHP","DrugName":"AZATHIOPRINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99406010000305","GenericName":"AZATHIOPRINE TAB 50 MG","NDC":"68462050201"},{"Id":412529,"FormularyType":"OHP","DrugName":"HAILEY FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"68462050329"},{"Id":412530,"FormularyType":"OHP","DrugName":"HAILEY FE TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"68462050384"},{"Id":412531,"FormularyType":"OHP","DrugName":"HAILEY TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"68462050479"},{"Id":412532,"FormularyType":"OHP","DrugName":"HAILEY TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"68462050481"},{"Id":412533,"FormularyType":"OHP","DrugName":"CLINDAMYCIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020100120","GenericName":"CLINDAMYCIN HCL CAP 300 MG","NDC":"68462052281"},{"Id":412534,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"68462053435"},{"Id":412535,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"68462053465"},{"Id":412536,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.1%","DosageForm":"OINT - Ointment","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004230","GenericName":"TACROLIMUS OINT 0.1%","NDC":"68462053494"},{"Id":412537,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"68462053601"},{"Id":412538,"FormularyType":"OHP","DrugName":"IMIQUIMOD CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOMODULATING AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90773040003720","GenericName":"IMIQUIMOD CREAM 5%","NDC":"68462053670"},{"Id":412539,"FormularyType":"OHP","DrugName":"ALYACEN TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"68462055629"},{"Id":412540,"FormularyType":"OHP","DrugName":"ALYACEN TAB 7/7/7","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002200310","GenericName":"NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","NDC":"68462055684"},{"Id":412541,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"68462056201"},{"Id":412542,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"68462056529"},{"Id":412543,"FormularyType":"OHP","DrugName":"NORGEST/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"68462056584"},{"Id":412544,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150310","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"68462057601"},{"Id":412545,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150320","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"68462057701"},{"Id":412546,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150330","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"68462057801"},{"Id":412547,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150340","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"68462057901"},{"Id":412548,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 67MG","DosageForm":"CAPS - Capsule","Strength":"67","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100107","GenericName":"FENOFIBRATE MICRONIZED CAP 67 MG","NDC":"68462058001"},{"Id":412549,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 134MG","DosageForm":"CAPS - Capsule","Strength":"134","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100115","GenericName":"FENOFIBRATE MICRONIZED CAP 134 MG","NDC":"68462058101"},{"Id":412550,"FormularyType":"OHP","DrugName":"FENOFIBRATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025100130","GenericName":"FENOFIBRATE MICRONIZED CAP 200 MG","NDC":"68462058201"},{"Id":412551,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"68462058340"},{"Id":412552,"FormularyType":"OHP","DrugName":"APREPITANT CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000110","GenericName":"APREPITANT CAPSULE 40 MG","NDC":"68462058385"},{"Id":412553,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"68462058440"},{"Id":412554,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"68462058458"},{"Id":412555,"FormularyType":"OHP","DrugName":"APREPITANT CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50280020000120","GenericName":"APREPITANT CAPSULE 80 MG","NDC":"68462058476"},{"Id":412556,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"68462060935"},{"Id":412557,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"68462060965"},{"Id":412558,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"68462060994"},{"Id":412559,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"68462062102"},{"Id":412560,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 100/2ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102024","GenericName":"FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","NDC":"68462062154"},{"Id":412561,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"68462062210"},{"Id":412562,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"68462062264"},{"Id":412563,"FormularyType":"OHP","DrugName":"AZELAIC ACID GEL 15%","DosageForm":"GEL - Gel","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060010004020","GenericName":"AZELAIC ACID GEL 15%","NDC":"68462062652"},{"Id":412564,"FormularyType":"OHP","DrugName":"LEVO-ETH EST TAB 90-20MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25994002350320","GenericName":"LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","NDC":"68462063729"},{"Id":412565,"FormularyType":"OHP","DrugName":"LEVO-ETH EST TAB 90-20MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25994002350320","GenericName":"LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","NDC":"68462063784"},{"Id":412566,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"68462063801"},{"Id":412567,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"68462063901"},{"Id":412568,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"68462063925"},{"Id":412569,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"68462063945"},{"Id":412570,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"68462064001"},{"Id":412571,"FormularyType":"OHP","DrugName":"ASHLYNA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"68462064691"},{"Id":412572,"FormularyType":"OHP","DrugName":"ASHLYNA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"68462064693"},{"Id":412573,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"68462064701"},{"Id":412574,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"68462064901"},{"Id":412575,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"68462065101"},{"Id":412576,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"68462065201"},{"Id":412577,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"68462065301"},{"Id":412578,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"68462067291"},{"Id":412579,"FormularyType":"OHP","DrugName":"LEVONOR/ETHI TAB ESTRADIO","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"68462067295"},{"Id":412580,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"68462067860"},{"Id":412581,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"68462067960"},{"Id":412582,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"68462068060"},{"Id":412583,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"68462068160"},{"Id":412584,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000310","GenericName":"SIROLIMUS TAB 0.5 MG","NDC":"68462068201"},{"Id":412585,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000320","GenericName":"SIROLIMUS TAB 1 MG","NDC":"68462068301"},{"Id":412586,"FormularyType":"OHP","DrugName":"SIROLIMUS TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070000330","GenericName":"SIROLIMUS TAB 2 MG","NDC":"68462068401"},{"Id":412587,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"68462068501"},{"Id":412588,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"68462068601"},{"Id":412589,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"68462068701"},{"Id":412590,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"68462071171"},{"Id":412591,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"68462071176"},{"Id":412592,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"68462071182"},{"Id":412593,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"68462071188"},{"Id":412594,"FormularyType":"OHP","DrugName":"DROSPIRENONE TAB ETHY EST","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"68462072029"},{"Id":412595,"FormularyType":"OHP","DrugName":"DROSPIRENONE TAB ETHY EST","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"68462072084"},{"Id":412596,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"68462072101"},{"Id":412597,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"68462072201"},{"Id":412598,"FormularyType":"OHP","DrugName":"HAILEY 24 TAB FE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"68462073129"},{"Id":412599,"FormularyType":"OHP","DrugName":"HAILEY 24 TAB FE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610312","GenericName":"NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","NDC":"68462073184"},{"Id":412600,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"68462073329"},{"Id":412601,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"68462073384"},{"Id":412602,"FormularyType":"OHP","DrugName":"TRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21708080000110","GenericName":"TRETINOIN CAP 10 MG","NDC":"68462079201"},{"Id":412603,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"68462085001"},{"Id":412604,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"68462085101"},{"Id":412605,"FormularyType":"OHP","DrugName":"CHARLOTTE 24 CHW FE 1/20","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"68462085229"},{"Id":412606,"FormularyType":"OHP","DrugName":"CHARLOTTE 24 CHW FE 1/20","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"68462085284"},{"Id":412607,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"68462086635"},{"Id":412608,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"68462086665"},{"Id":412609,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"68462087801"},{"Id":412610,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"68462087805"},{"Id":412611,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"68462087830"},{"Id":412612,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"68462087901"},{"Id":412613,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"68462087905"},{"Id":412614,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"68462087930"},{"Id":412615,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"68462088001"},{"Id":412616,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"68462088005"},{"Id":412617,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"68462088030"},{"Id":412618,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"68462088135"},{"Id":412619,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"68462088165"},{"Id":412620,"FormularyType":"OHP","DrugName":"TACROLIMUS OIN 0.03%","DosageForm":"OINT - Ointment","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784075004210","GenericName":"TACROLIMUS OINT 0.03%","NDC":"68462088194"},{"Id":412621,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"68462088260"},{"Id":412622,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"68462088901"},{"Id":412623,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"68462089356"},{"Id":412624,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"68462089404"},{"Id":412625,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"68462089456"},{"Id":412626,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"68462089504"},{"Id":412627,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"68462089601"},{"Id":412628,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"68462089610"},{"Id":412629,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"68462094086"},{"Id":412630,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"68462094303"},{"Id":412631,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"68462094305"},{"Id":412632,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"68462094403"},{"Id":412633,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"68462094510"},{"Id":412634,"FormularyType":"OHP","DrugName":"FOSPHENYTOIN INJ 500/10ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"HYDANTOINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72200013102028","GenericName":"FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","NDC":"68462094564"},{"Id":412635,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68462094701"},{"Id":412636,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"68462095150"},{"Id":412637,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"68462095165"},{"Id":412638,"FormularyType":"OHP","DrugName":"MAG64 TAB 64MG","DosageForm":"TBEC - Tablet DR","Strength":"64","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010200614","GenericName":"MAGNESIUM CHLORIDE TAB DR 64 MG (ELEMENTAL MG)","NDC":"68585000575"},{"Id":412639,"FormularyType":"OHP","DrugName":"PREVENT SAFE MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"68599857710"},{"Id":412640,"FormularyType":"OHP","DrugName":"PREVENT SAFE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"68599857810"},{"Id":412641,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"68645019059"},{"Id":412642,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"68645019159"},{"Id":412643,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"68645047954"},{"Id":412644,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"68645051054"},{"Id":412645,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"68645051554"},{"Id":412646,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68645051654"},{"Id":412647,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"68645052470"},{"Id":412648,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"68645052670"},{"Id":412649,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"68645054154"},{"Id":412650,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"68645055654"},{"Id":412651,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"68645055754"},{"Id":412652,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"68645055854"},{"Id":412653,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"68645056259"},{"Id":412654,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"68645056354"},{"Id":412655,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000310","GenericName":"LOVASTATIN TAB 20 MG","NDC":"68645056690"},{"Id":412656,"FormularyType":"OHP","DrugName":"LOVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400050000320","GenericName":"LOVASTATIN TAB 40 MG","NDC":"68645056790"},{"Id":412657,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"68645057454"},{"Id":412658,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"68645057559"},{"Id":412659,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"68645058054"},{"Id":412660,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"68645058259"},{"Id":412661,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"68645058359"},{"Id":412662,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"68645058459"},{"Id":412663,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"68645059090"},{"Id":412664,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"68645059459"},{"Id":412665,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"68645059559"},{"Id":412666,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"68645060590"},{"Id":412667,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"68645060690"},{"Id":412668,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"68645060790"},{"Id":412669,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"68645060890"},{"Id":412670,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"68645060990"},{"Id":412671,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"68645061090"},{"Id":412672,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"68645061190"},{"Id":412673,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"68645061290"},{"Id":412674,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"68645061390"},{"Id":412675,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"68682000610"},{"Id":412676,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100305","GenericName":"DILTIAZEM HCL TAB 30 MG","NDC":"68682000650"},{"Id":412677,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"68682000710"},{"Id":412678,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100310","GenericName":"DILTIAZEM HCL TAB 60 MG","NDC":"68682000750"},{"Id":412679,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"68682000810"},{"Id":412680,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100315","GenericName":"DILTIAZEM HCL TAB 90 MG","NDC":"68682000850"},{"Id":412681,"FormularyType":"OHP","DrugName":"DILTIAZEM TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010100320","GenericName":"DILTIAZEM HCL TAB 120 MG","NDC":"68682000910"},{"Id":412682,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007207530","GenericName":"DICLOFENAC SODIUM TAB ER 24HR 100 MG","NDC":"68682010301"},{"Id":412683,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007530","GenericName":"NIFEDIPINE TAB ER 24HR 30 MG","NDC":"68682010510"},{"Id":412684,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007530","GenericName":"NIFEDIPINE TAB ER 24HR 30 MG","NDC":"68682010530"},{"Id":412685,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007540","GenericName":"NIFEDIPINE TAB ER 24HR 60 MG","NDC":"68682010610"},{"Id":412686,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007540","GenericName":"NIFEDIPINE TAB ER 24HR 60 MG","NDC":"68682010630"},{"Id":412687,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 90MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007550","GenericName":"NIFEDIPINE TAB ER 24HR 90 MG","NDC":"68682010710"},{"Id":412688,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"68682010810"},{"Id":412689,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 30MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007570","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","NDC":"68682010830"},{"Id":412690,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"68682010910"},{"Id":412691,"FormularyType":"OHP","DrugName":"NIFEDIPINE TAB 60MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020007575","GenericName":"NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","NDC":"68682010930"},{"Id":412692,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"68682011001"},{"Id":412693,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"68682011102"},{"Id":412694,"FormularyType":"OHP","DrugName":"PIMECROLIMUS CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784060003720","GenericName":"PIMECROLIMUS CREAM 1%","NDC":"68682011203"},{"Id":412695,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"68682019301"},{"Id":412696,"FormularyType":"OHP","DrugName":"DESMOPRESSIN SPR 0.01%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010122010","GenericName":"DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED)","NDC":"68682034205"},{"Id":412697,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117020","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG","NDC":"68682036790"},{"Id":412698,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117030","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","NDC":"68682036890"},{"Id":412699,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117040","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","NDC":"68682036990"},{"Id":412700,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117050","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","NDC":"68682037090"},{"Id":412701,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 360MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117060","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","NDC":"68682037190"},{"Id":412702,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 420MG/24","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"420","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010117070","GenericName":"DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 420 MG","NDC":"68682037290"},{"Id":412703,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"68682042112"},{"Id":412704,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"68682042225"},{"Id":412705,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 1XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104006","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (ONCE-DAILY)","NDC":"68682046275"},{"Id":412706,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 2.5MG","DosageForm":"GEL - Gel","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004030","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG","NDC":"68682065020"},{"Id":412707,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 10MG","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004040","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG","NDC":"68682065220"},{"Id":412708,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 20MG","DosageForm":"GEL - Gel","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004060","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG","NDC":"68682065520"},{"Id":412709,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127020","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","NDC":"68682099398"},{"Id":412710,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127030","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","NDC":"68682099498"},{"Id":412711,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127040","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","NDC":"68682099798"},{"Id":412712,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 300MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010127050","GenericName":"DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","NDC":"68682099898"},{"Id":412713,"FormularyType":"OHP","DrugName":"MODEYSO CAP 125MG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - PROTEASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21580015200120","GenericName":"DORDAVIPRONE HCL CAP 125 MG","NDC":"68727025001"},{"Id":412714,"FormularyType":"OHP","DrugName":"BISACODYL SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"68784010212"},{"Id":412715,"FormularyType":"OHP","DrugName":"COMBIPATCH DIS","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002128720","GenericName":"ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.14 MG/DAY","NDC":"68968051408"},{"Id":412716,"FormularyType":"OHP","DrugName":"COMBIPATCH DIS","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002128730","GenericName":"ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.25 MG/DAY","NDC":"68968052508"},{"Id":412717,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"68968341001"},{"Id":412718,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"68968341008"},{"Id":412719,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"68968342501"},{"Id":412720,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"68968342508"},{"Id":412721,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"68968343701"},{"Id":412722,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"68968343708"},{"Id":412723,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"68968345001"},{"Id":412724,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"68968345008"},{"Id":412725,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"68968347501"},{"Id":412726,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"68968347508"},{"Id":412727,"FormularyType":"OHP","DrugName":"FILSPARI TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"IGA NEPHROPATHY (IGAN) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56483065000320","GenericName":"SPARSENTAN TAB 200 MG","NDC":"68974020030"},{"Id":412728,"FormularyType":"OHP","DrugName":"FILSPARI TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"IGA NEPHROPATHY (IGAN) AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56483065000340","GenericName":"SPARSENTAN TAB 400 MG","NDC":"68974040030"},{"Id":412729,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"68999000224"},{"Id":412730,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"68999000251"},{"Id":412731,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"68999000424"},{"Id":412732,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 20/30ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"68999000443"},{"Id":412733,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"68999001124"},{"Id":412734,"FormularyType":"OHP","DrugName":"AMANTADINE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010102005","GenericName":"AMANTADINE HCL SOLN 50 MG/5ML","NDC":"68999001159"},{"Id":412735,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"68999018905"},{"Id":412736,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 8MG/20ML","DosageForm":"SYRP - Syrup","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"68999018920"},{"Id":412737,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 8MG/20ML","DosageForm":"SYRP - Syrup","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"68999018923"},{"Id":412738,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"68999018924"},{"Id":412739,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"68999025024"},{"Id":412740,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040002020","GenericName":"PREDNISOLONE SOLN 15 MG/5ML","NDC":"68999025045"},{"Id":412741,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"68999030928"},{"Id":412742,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202040","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 5 MG/5ML (BASE EQUIV)","NDC":"68999033005"},{"Id":412743,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202040","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 5 MG/5ML (BASE EQUIV)","NDC":"68999033024"},{"Id":412744,"FormularyType":"OHP","DrugName":"K CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202022002025","GenericName":"POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML","NDC":"68999043505"},{"Id":412745,"FormularyType":"OHP","DrugName":"K CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202022002025","GenericName":"POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML","NDC":"68999043524"},{"Id":412746,"FormularyType":"OHP","DrugName":"METOCLOPRAM SOL 10/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102013","GenericName":"METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","NDC":"68999052610"},{"Id":412747,"FormularyType":"OHP","DrugName":"METOCLOPRAM SOL 10/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102013","GenericName":"METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","NDC":"68999052624"},{"Id":412748,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"68999055524"},{"Id":412749,"FormularyType":"OHP","DrugName":"ONDANSETRON SOL 4MG/5ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"50250065052070","GenericName":"ONDANSETRON HCL ORAL SOLN 4 MG/5ML","NDC":"68999055545"},{"Id":412750,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"68999062696"},{"Id":412751,"FormularyType":"OHP","DrugName":"LAMIVUDINE SOL 300/30ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060002020","GenericName":"LAMIVUDINE ORAL SOLN 10 MG/ML","NDC":"68999070624"},{"Id":412752,"FormularyType":"OHP","DrugName":"LAMIVUDINE SOL 300/30ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106060002020","GenericName":"LAMIVUDINE ORAL SOLN 10 MG/ML","NDC":"68999070630"},{"Id":412753,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"68999080305"},{"Id":412754,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 800/20ML","DosageForm":"SUSP - Suspension","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"68999080320"},{"Id":412755,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 800/20ML","DosageForm":"SUSP - Suspension","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"68999080323"},{"Id":412756,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"68999080324"},{"Id":412757,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"68999084124"},{"Id":412758,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"68999084145"},{"Id":412759,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% VISC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"68999087124"},{"Id":412760,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% VISC","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"68999087151"},{"Id":412761,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"68999096205"},{"Id":412762,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 30/7.5ML","DosageForm":"ELIX - Elixir","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"68999096207"},{"Id":412763,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 60/15ML","DosageForm":"ELIX - Elixir","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"68999096215"},{"Id":412764,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 60/15ML","DosageForm":"ELIX - Elixir","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"68999096222"},{"Id":412765,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 30/7.5ML","DosageForm":"ELIX - Elixir","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"68999096223"},{"Id":412766,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"68999096224"},{"Id":412767,"FormularyType":"OHP","DrugName":"IMPAVIDO CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000036000120","GenericName":"MILTEFOSINE CAP 50 MG","NDC":"69051030001"},{"Id":412768,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"69076010503"},{"Id":412769,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"69076014601"},{"Id":412770,"FormularyType":"OHP","DrugName":"RILUZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74503070000320","GenericName":"RILUZOLE TAB 50 MG","NDC":"69076020060"},{"Id":412771,"FormularyType":"OHP","DrugName":"HYDRO SOD SU INJ 100MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025402150","GenericName":"HYDROCORTISONE SODIUM SUCCINATE PF FOR INJ 100 MG","NDC":"69097000467"},{"Id":412772,"FormularyType":"OHP","DrugName":"GLUCAGON INJ 1MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010002105","GenericName":"GLUCAGON FOR INJ 1 MG","NDC":"69097002750"},{"Id":412773,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"69097009808"},{"Id":412774,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"69097009843"},{"Id":412775,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"69097009844"},{"Id":412776,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"69097012203"},{"Id":412777,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"69097012212"},{"Id":412778,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"69097012215"},{"Id":412779,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"69097012303"},{"Id":412780,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"69097012312"},{"Id":412781,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"69097012315"},{"Id":412782,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"69097012403"},{"Id":412783,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"69097012412"},{"Id":412784,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"69097012415"},{"Id":412785,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"69097012503"},{"Id":412786,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"69097012512"},{"Id":412787,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"69097012515"},{"Id":412788,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"69097012605"},{"Id":412789,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"69097012615"},{"Id":412790,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69097012705"},{"Id":412791,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69097012715"},{"Id":412792,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69097012805"},{"Id":412793,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69097012815"},{"Id":412794,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"69097014260"},{"Id":412795,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"69097015807"},{"Id":412796,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"69097015812"},{"Id":412797,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"69097015815"},{"Id":412798,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"69097015907"},{"Id":412799,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"69097015912"},{"Id":412800,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"69097015915"},{"Id":412801,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"69097017353"},{"Id":412802,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"69097017364"},{"Id":412803,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"69097022316"},{"Id":412804,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"69097022376"},{"Id":412805,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"69097022416"},{"Id":412806,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"69097022476"},{"Id":412807,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"69097024402"},{"Id":412808,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"69097024803"},{"Id":412809,"FormularyType":"OHP","DrugName":"EFAVIRENZ TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109030000330","GenericName":"EFAVIRENZ TAB 600 MG","NDC":"69097030102"},{"Id":412810,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"69097031602"},{"Id":412811,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"69097031832"},{"Id":412812,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"69097031853"},{"Id":412813,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"69097031886"},{"Id":412814,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"69097031887"},{"Id":412815,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"69097031932"},{"Id":412816,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"69097031953"},{"Id":412817,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"69097031986"},{"Id":412818,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"69097031987"},{"Id":412819,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"69097032132"},{"Id":412820,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"69097032153"},{"Id":412821,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"69097032186"},{"Id":412822,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"69097032187"},{"Id":412823,"FormularyType":"OHP","DrugName":"GRISEOFULVIN SUS 125/5ML","DosageForm":"SUSP - Suspension","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000030101805","GenericName":"GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML","NDC":"69097036108"},{"Id":412824,"FormularyType":"OHP","DrugName":"ABACA/LAMIVU TAB 600-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902200340","GenericName":"ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG","NDC":"69097036202"},{"Id":412825,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"69097038173"},{"Id":412826,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"69097038273"},{"Id":412827,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"69097038381"},{"Id":412828,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"69097038481"},{"Id":412829,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"69097038581"},{"Id":412830,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"69097038602"},{"Id":412831,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"69097038702"},{"Id":412832,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"69097040715"},{"Id":412833,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"69097040815"},{"Id":412834,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"69097040907"},{"Id":412835,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"69097041002"},{"Id":412836,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"69097041102"},{"Id":412837,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"69097041202"},{"Id":412838,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69097042107"},{"Id":412839,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69097042112"},{"Id":412840,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69097042207"},{"Id":412841,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69097042212"},{"Id":412842,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"69097045805"},{"Id":412843,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"69097045905"},{"Id":412844,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"69097051403"},{"Id":412845,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000105","GenericName":"CYCLOPHOSPHAMIDE CAP 25 MG","NDC":"69097051607"},{"Id":412846,"FormularyType":"OHP","DrugName":"CYCLOPHOSPH CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101020000110","GenericName":"CYCLOPHOSPHAMIDE CAP 50 MG","NDC":"69097051707"},{"Id":412847,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"69097052603"},{"Id":412848,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"69097053302"},{"Id":412849,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"69097053731"},{"Id":412850,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"69097057967"},{"Id":412851,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"69097060473"},{"Id":412852,"FormularyType":"OHP","DrugName":"EMTRICITABIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12106030000120","GenericName":"EMTRICITABINE CAPS 200 MG","NDC":"69097064202"},{"Id":412853,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 20MG/ACT","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002040","GenericName":"SUMATRIPTAN NASAL SPRAY 20 MG/ACT","NDC":"69097064448"},{"Id":412854,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"69097066434"},{"Id":412855,"FormularyType":"OHP","DrugName":"ICATIBANT INJ 30MG/3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"BRADYKININ B2 RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8582004010E520","GenericName":"ICATIBANT ACETATE SUBCUTANEOUS SOLN PREF SYR 30 MG/3ML","NDC":"69097066468"},{"Id":412856,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"69097072044"},{"Id":412857,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"69097078805"},{"Id":412858,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"69097078812"},{"Id":412859,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"69097078905"},{"Id":412860,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"69097078912"},{"Id":412861,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"69097079105"},{"Id":412862,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"69097079112"},{"Id":412863,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"69097079205"},{"Id":412864,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"69097079212"},{"Id":412865,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"69097080232"},{"Id":412866,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"69097081307"},{"Id":412867,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"69097081312"},{"Id":412868,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"69097081507"},{"Id":412869,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"69097082103"},{"Id":412870,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"69097082112"},{"Id":412871,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"69097082502"},{"Id":412872,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"69097082507"},{"Id":412873,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"69097082515"},{"Id":412874,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"69097084064"},{"Id":412875,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"69097084087"},{"Id":412876,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"69097084507"},{"Id":412877,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"69097084607"},{"Id":412878,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"69097084615"},{"Id":412879,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"69097085605"},{"Id":412880,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"69097085705"},{"Id":412881,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"69097085805"},{"Id":412882,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"69097085902"},{"Id":412883,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"69097085907"},{"Id":412884,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"69097086107"},{"Id":412885,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"69097086283"},{"Id":412886,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"69097089705"},{"Id":412887,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"69097089715"},{"Id":412888,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"69097089812"},{"Id":412889,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"69097089905"},{"Id":412890,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"69097089915"},{"Id":412891,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"69097091112"},{"Id":412892,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"69097091203"},{"Id":412893,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"69097092067"},{"Id":412894,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"69097092068"},{"Id":412895,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"69097093457"},{"Id":412896,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"69097093498"},{"Id":412897,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"69097093589"},{"Id":412898,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"69097093598"},{"Id":412899,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"69097093665"},{"Id":412900,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"69097093698"},{"Id":412901,"FormularyType":"OHP","DrugName":"PIRFENIDONE CAP 267MG","DosageForm":"CAPS - Capsule","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000120","GenericName":"PIRFENIDONE CAP 267 MG","NDC":"69097094093"},{"Id":412902,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"69097094312"},{"Id":412903,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"69097096453"},{"Id":412904,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"69097096507"},{"Id":412905,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"69097096512"},{"Id":412906,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"69097096607"},{"Id":412907,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"69097096612"},{"Id":412908,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"69097096793"},{"Id":412909,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"69097098793"},{"Id":412910,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"69097098805"},{"Id":412911,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"69097099902"},{"Id":412912,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"69097099907"},{"Id":412913,"FormularyType":"OHP","DrugName":"ROWEEPRA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"69102010501"},{"Id":412914,"FormularyType":"OHP","DrugName":"ANASTROZOLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402810000310","GenericName":"ANASTROZOLE TAB 1 MG","NDC":"69117000301"},{"Id":412915,"FormularyType":"OHP","DrugName":"LETROZOLE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402860000320","GenericName":"LETROZOLE TAB 2.5 MG","NDC":"69117000401"},{"Id":412916,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"69117000801"},{"Id":412917,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"69117000901"},{"Id":412918,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"69117000902"},{"Id":412919,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"69117001801"},{"Id":412920,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"69117001802"},{"Id":412921,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"69117001901"},{"Id":412922,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"69117001902"},{"Id":412923,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69117002102"},{"Id":412924,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69117002103"},{"Id":412925,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69117002202"},{"Id":412926,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69117002203"},{"Id":412927,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"69117002801"},{"Id":412928,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"69117002802"},{"Id":412929,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"69117002901"},{"Id":412930,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"69117002902"},{"Id":412931,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"69117003001"},{"Id":412932,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"69117003002"},{"Id":412933,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"69117101001"},{"Id":412934,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"69117101002"},{"Id":412935,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"69117101003"},{"Id":412936,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"69117101004"},{"Id":412937,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"69150002010"},{"Id":412938,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"69150011310"},{"Id":412939,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69150011490"},{"Id":412940,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69150011510"},{"Id":412941,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"69150013814"},{"Id":412942,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"69150013815"},{"Id":412943,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"69150013816"},{"Id":412944,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"69150013914"},{"Id":412945,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"69150013915"},{"Id":412946,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"69150013916"},{"Id":412947,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"69150014014"},{"Id":412948,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"69150014015"},{"Id":412949,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"69150014016"},{"Id":412950,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"69150060010"},{"Id":412951,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"69150060050"},{"Id":412952,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"69150080010"},{"Id":412953,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"69150080050"},{"Id":412954,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69230014620"},{"Id":412955,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69230014640"},{"Id":412956,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69230014652"},{"Id":412957,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69230014680"},{"Id":412958,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"69230020101"},{"Id":412959,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"69230020105"},{"Id":412960,"FormularyType":"OHP","DrugName":"ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"69230020230"},{"Id":412961,"FormularyType":"OHP","DrugName":"ALLERGY 24HR TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"69230020260"},{"Id":412962,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"69230030001"},{"Id":412963,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"69230030005"},{"Id":412964,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"69230030030"},{"Id":412965,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"69230030401"},{"Id":412966,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"69230030405"},{"Id":412967,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230030811"},{"Id":412968,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230030812"},{"Id":412969,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230030911"},{"Id":412970,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230030912"},{"Id":412971,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230031011"},{"Id":412972,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230031012"},{"Id":412973,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230031111"},{"Id":412974,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69230031112"},{"Id":412975,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"69230031611"},{"Id":412976,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"69230032031"},{"Id":412977,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"69230032032"},{"Id":412978,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"69230032033"},{"Id":412979,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"69230032212"},{"Id":412980,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"69230032224"},{"Id":412981,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69230032330"},{"Id":412982,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69230032333"},{"Id":412983,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69230032334"},{"Id":412984,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"69230032434"},{"Id":412985,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"69230032435"},{"Id":412986,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"69230032436"},{"Id":412987,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"69230032437"},{"Id":412988,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"69230032601"},{"Id":412989,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"69230032605"},{"Id":412990,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"69230032610"},{"Id":412991,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"69230032630"},{"Id":412992,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"69230032660"},{"Id":412993,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"69230032701"},{"Id":412994,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"69230032705"},{"Id":412995,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"69230032710"},{"Id":412996,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"69230032730"},{"Id":412997,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"69230032750"},{"Id":412998,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69230032801"},{"Id":412999,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69230032803"},{"Id":413000,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"69238101302"},{"Id":413001,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"69238101701"},{"Id":413002,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"69238101703"},{"Id":413003,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"69238105103"},{"Id":413004,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"69238110002"},{"Id":413005,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"69238110005"},{"Id":413006,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"69238112309"},{"Id":413007,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"69238112409"},{"Id":413008,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"69238112509"},{"Id":413009,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"69238115403"},{"Id":413010,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"69238115405"},{"Id":413011,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"69238115409"},{"Id":413012,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"69238116507"},{"Id":413013,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"69238117401"},{"Id":413014,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"69238117403"},{"Id":413015,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"69238117501"},{"Id":413016,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"69238117503"},{"Id":413017,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"69238117601"},{"Id":413018,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"69238117603"},{"Id":413019,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 5MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008820","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR","NDC":"69238120202"},{"Id":413020,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 10MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008830","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 10 MCG/HR","NDC":"69238120302"},{"Id":413021,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 15MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008835","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 15 MCG/HR","NDC":"69238120402"},{"Id":413022,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 20MCG/HR","DosageForm":"PTWK - Patch Weekly","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008840","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 20 MCG/HR","NDC":"69238120502"},{"Id":413023,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"69238126401"},{"Id":413024,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"69238126501"},{"Id":413025,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"69238126601"},{"Id":413026,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"69238127306"},{"Id":413027,"FormularyType":"OHP","DrugName":"BECLOMETHASO AER 40MCG","DosageForm":"AERS - Aerosol solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400010103408","GenericName":"BECLOMETHASONE DIPROP INHAL AERO SOLN 40 MCG/ACT (50/VALVE)","NDC":"69238128904"},{"Id":413028,"FormularyType":"OHP","DrugName":"BECLOMETHASO AER 80MCG","DosageForm":"AERS - Aerosol solution","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400010103428","GenericName":"BECLOMETHASONE DIPROP INHAL AERS 100 MCG/ACT (80/DELIVERY)","NDC":"69238129004"},{"Id":413029,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"69238130501"},{"Id":413030,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"69238130601"},{"Id":413031,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"69238131009"},{"Id":413032,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"69238131109"},{"Id":413033,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"69238131209"},{"Id":413034,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"69238131309"},{"Id":413035,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"69238131409"},{"Id":413036,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"69238131509"},{"Id":413037,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"69238131609"},{"Id":413038,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"69238131709"},{"Id":413039,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"69238131804"},{"Id":413040,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"69238131906"},{"Id":413041,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000310","GenericName":"ETODOLAC TAB 400 MG","NDC":"69238134201"},{"Id":413042,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000320","GenericName":"ETODOLAC TAB 500 MG","NDC":"69238134301"},{"Id":413043,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"69238134401"},{"Id":413044,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"69238134501"},{"Id":413045,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"69238142501"},{"Id":413046,"FormularyType":"OHP","DrugName":"VIGABATRIN PAK 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085003020","GenericName":"VIGABATRIN POWD PACK 500 MG","NDC":"69238142505"},{"Id":413047,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"69238145802"},{"Id":413048,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"69238145902"},{"Id":413049,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"69238147606"},{"Id":413050,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"69238148901"},{"Id":413051,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"69238149001"},{"Id":413052,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"69238149005"},{"Id":413053,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"69238149101"},{"Id":413054,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"69238149105"},{"Id":413055,"FormularyType":"OHP","DrugName":"BUPRENORPHIN DIS 7.5/HR","DosageForm":"PTWK - Patch Weekly","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010008825","GenericName":"BUPRENORPHINE TD PATCH WEEKLY 7.5 MCG/HR","NDC":"69238150502"},{"Id":413056,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100105","GenericName":"TETRACYCLINE HCL CAP 250 MG","NDC":"69238152201"},{"Id":413057,"FormularyType":"OHP","DrugName":"TETRACYCLINE CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000060100110","GenericName":"TETRACYCLINE HCL CAP 500 MG","NDC":"69238152301"},{"Id":413058,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"69238153203"},{"Id":413059,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"69238153204"},{"Id":413060,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"69238153205"},{"Id":413061,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"69238153206"},{"Id":413062,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"69238153502"},{"Id":413063,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"69238154401"},{"Id":413064,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"69238154405"},{"Id":413065,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"69238159403"},{"Id":413066,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"69238159406"},{"Id":413067,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"69238159502"},{"Id":413068,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"69238160502"},{"Id":413069,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"69238160508"},{"Id":413070,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"69238161503"},{"Id":413071,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"69238161606"},{"Id":413072,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP STARTER","DosageForm":"CDPK - CPDR Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6240552500B320","GenericName":"DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG","NDC":"69238162603"},{"Id":413073,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"69238165601"},{"Id":413074,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"69238173102"},{"Id":413075,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102015","GenericName":"PILOCARPINE HCL OPHTH SOLN 1%","NDC":"69238174508"},{"Id":413076,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102020","GenericName":"PILOCARPINE HCL OPHTH SOLN 2%","NDC":"69238174608"},{"Id":413077,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 4% OP","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102030","GenericName":"PILOCARPINE HCL OPHTH SOLN 4%","NDC":"69238174708"},{"Id":413078,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"69238175406"},{"Id":413079,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"69238183001"},{"Id":413080,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"69238183007"},{"Id":413081,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"69238183101"},{"Id":413082,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"69238183107"},{"Id":413083,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"69238183201"},{"Id":413084,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"69238183207"},{"Id":413085,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"69238183301"},{"Id":413086,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"69238183307"},{"Id":413087,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"69238183401"},{"Id":413088,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"69238183407"},{"Id":413089,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"69238183501"},{"Id":413090,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"69238183507"},{"Id":413091,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"69238183601"},{"Id":413092,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"69238183607"},{"Id":413093,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"69238183701"},{"Id":413094,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"69238183707"},{"Id":413095,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"69238183801"},{"Id":413096,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"69238183807"},{"Id":413097,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"69238183901"},{"Id":413098,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"69238183907"},{"Id":413099,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"69238184001"},{"Id":413100,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"69238184007"},{"Id":413101,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"69238184101"},{"Id":413102,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"69238199101"},{"Id":413103,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"69238199107"},{"Id":413104,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"69238199201"},{"Id":413105,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"69238199207"},{"Id":413106,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"69238201603"},{"Id":413107,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 1XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104006","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (ONCE-DAILY)","NDC":"69238203107"},{"Id":413108,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"69238205301"},{"Id":413109,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"69238207701"},{"Id":413110,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"69238207707"},{"Id":413111,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"69238207801"},{"Id":413112,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"69238207807"},{"Id":413113,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"69238207901"},{"Id":413114,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"69238207907"},{"Id":413115,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"69238208001"},{"Id":413116,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"69238208101"},{"Id":413117,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"69238208105"},{"Id":413118,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"69238209004"},{"Id":413119,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 100-150","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300308","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG","NDC":"69238209203"},{"Id":413120,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 133-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300312","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 133-200 MG","NDC":"69238209303"},{"Id":413121,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 167-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300316","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG","NDC":"69238209403"},{"Id":413122,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"69238209503"},{"Id":413123,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"69238210401"},{"Id":413124,"FormularyType":"OHP","DrugName":"NALOXONE HCL SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"69238210407"},{"Id":413125,"FormularyType":"OHP","DrugName":"PREDNISOLONE SOL 15MG/5ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100040202020","GenericName":"PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)","NDC":"69238212209"},{"Id":413126,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"69238269301"},{"Id":413127,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"69238273101"},{"Id":413128,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"69238273102"},{"Id":413129,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"69238273201"},{"Id":413130,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"69238273202"},{"Id":413131,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"69238273301"},{"Id":413132,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"69238273302"},{"Id":413133,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"69292020750"},{"Id":413134,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"69292020850"},{"Id":413135,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"69292022501"},{"Id":413136,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"69292022530"},{"Id":413137,"FormularyType":"OHP","DrugName":"PILOCARPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"THROAT PRODUCTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88501560100310","GenericName":"PILOCARPINE HCL TAB 5 MG","NDC":"69292026501"},{"Id":413138,"FormularyType":"OHP","DrugName":"CEFPODOXIME TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300065100320","GenericName":"CEFPODOXIME PROXETIL TAB 100 MG","NDC":"69292051001"},{"Id":413139,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"69292052201"},{"Id":413140,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000305","GenericName":"CAPTOPRIL TAB 12.5 MG","NDC":"69292052210"},{"Id":413141,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"69292052401"},{"Id":413142,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000310","GenericName":"CAPTOPRIL TAB 25 MG","NDC":"69292052410"},{"Id":413143,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"69292052601"},{"Id":413144,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000315","GenericName":"CAPTOPRIL TAB 50 MG","NDC":"69292052610"},{"Id":413145,"FormularyType":"OHP","DrugName":"CAPTOPRIL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100010000320","GenericName":"CAPTOPRIL TAB 100 MG","NDC":"69292052801"},{"Id":413146,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"69292053001"},{"Id":413147,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"69292053010"},{"Id":413148,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"69292053201"},{"Id":413149,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"69292053210"},{"Id":413150,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"69292053401"},{"Id":413151,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"69292053410"},{"Id":413152,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"69292053601"},{"Id":413153,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"69292053801"},{"Id":413154,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"69292053850"},{"Id":413155,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"69292054001"},{"Id":413156,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100303","GenericName":"ENALAPRIL MALEATE TAB 2.5 MG","NDC":"69292054010"},{"Id":413157,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"69292054201"},{"Id":413158,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100305","GenericName":"ENALAPRIL MALEATE TAB 5 MG","NDC":"69292054210"},{"Id":413159,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"69292054401"},{"Id":413160,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100310","GenericName":"ENALAPRIL MALEATE TAB 10 MG","NDC":"69292054410"},{"Id":413161,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"69292054601"},{"Id":413162,"FormularyType":"OHP","DrugName":"ENALAPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100020100315","GenericName":"ENALAPRIL MALEATE TAB 20 MG","NDC":"69292054610"},{"Id":413163,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"69292055001"},{"Id":413164,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"69292055201"},{"Id":413165,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"69292056201"},{"Id":413166,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"69292056401"},{"Id":413167,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"69292056601"},{"Id":413168,"FormularyType":"OHP","DrugName":"DIGOXIN SOL 50MCG/ML","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010002040","GenericName":"DIGOXIN ORAL SOLN 0.05 MG/ML","NDC":"69292060560"},{"Id":413169,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"69292063020"},{"Id":413170,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"69292063028"},{"Id":413171,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"69292063130"},{"Id":413172,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"69292063190"},{"Id":413173,"FormularyType":"OHP","DrugName":"FLURBIPROFEN SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805020102010","GenericName":"FLURBIPROFEN SODIUM OPHTH SOLN 0.03%","NDC":"69292072225"},{"Id":413174,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"69315011601"},{"Id":413175,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"69315011610"},{"Id":413176,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"69315011701"},{"Id":413177,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"69315011710"},{"Id":413178,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"69315011801"},{"Id":413179,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"69315011805"},{"Id":413180,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"69315012701"},{"Id":413181,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"69315012710"},{"Id":413182,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"69315013001"},{"Id":413183,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"69315013010"},{"Id":413184,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"69315013101"},{"Id":413185,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"69315013110"},{"Id":413186,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"69315013601"},{"Id":413187,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"69315013610"},{"Id":413188,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"69315013701"},{"Id":413189,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"69315013710"},{"Id":413190,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"69315013801"},{"Id":413191,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"69315013810"},{"Id":413192,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"69315015501"},{"Id":413193,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000303","GenericName":"HYDROCHLOROTHIAZIDE TAB 12.5 MG","NDC":"69315015510"},{"Id":413194,"FormularyType":"OHP","DrugName":"HYDROXYUREA CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700030000105","GenericName":"HYDROXYUREA CAP 500 MG","NDC":"69315016401"},{"Id":413195,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"69315018201"},{"Id":413196,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"69315018205"},{"Id":413197,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"69315018210"},{"Id":413198,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"69315018401"},{"Id":413199,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100310","GenericName":"LEUCOVORIN CALCIUM TAB 5 MG","NDC":"69315018403"},{"Id":413200,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"69315018512"},{"Id":413201,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100325","GenericName":"LEUCOVORIN CALCIUM TAB 10 MG","NDC":"69315018524"},{"Id":413202,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100335","GenericName":"LEUCOVORIN CALCIUM TAB 15 MG","NDC":"69315018624"},{"Id":413203,"FormularyType":"OHP","DrugName":"LEUCOVOR CA TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21755040100345","GenericName":"LEUCOVORIN CALCIUM TAB 25 MG","NDC":"69315018725"},{"Id":413204,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000105","GenericName":"NIFEDIPINE CAP 10 MG","NDC":"69315021101"},{"Id":413205,"FormularyType":"OHP","DrugName":"NIFEDIPINE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000020000110","GenericName":"NIFEDIPINE CAP 20 MG","NDC":"69315021201"},{"Id":413206,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"69315022601"},{"Id":413207,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"69315022701"},{"Id":413208,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69315026501"},{"Id":413209,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69315026601"},{"Id":413210,"FormularyType":"OHP","DrugName":"FENOFIBRIC CAP 45MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200006006520","GenericName":"CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV)","NDC":"69315028109"},{"Id":413211,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000320","GenericName":"ETRAVIRINE TAB 100 MG","NDC":"69315028520"},{"Id":413212,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000340","GenericName":"ETRAVIRINE TAB 200 MG","NDC":"69315028606"},{"Id":413213,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"69315028709"},{"Id":413214,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"69315028805"},{"Id":413215,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"69315028809"},{"Id":413216,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"69315028909"},{"Id":413217,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"69315029005"},{"Id":413218,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"69315029009"},{"Id":413219,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"69315029101"},{"Id":413220,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"69315029105"},{"Id":413221,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"69315029110"},{"Id":413222,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"69315029201"},{"Id":413223,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"69315029205"},{"Id":413224,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"69315029210"},{"Id":413225,"FormularyType":"OHP","DrugName":"PROCTO-MED CRE HC 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"RECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89100010003720","GenericName":"HYDROCORTISONE PERIANAL CREAM 2.5%","NDC":"69315030230"},{"Id":413226,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"69315030410"},{"Id":413227,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"69315030510"},{"Id":413228,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"69315030615"},{"Id":413229,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"69315030630"},{"Id":413230,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"69315030660"},{"Id":413231,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"69315030715"},{"Id":413232,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"69315030730"},{"Id":413233,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"69315030802"},{"Id":413234,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"69315030805"},{"Id":413235,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"69315030810"},{"Id":413236,"FormularyType":"OHP","DrugName":"PROCTO-MED CRE HC 2.5%","DosageForm":"CREA - Cream","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANORECTAL AND RELATED PRODUCTS","DrugSubClass":"RECTAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"89100010003720","GenericName":"HYDROCORTISONE PERIANAL CREAM 2.5%","NDC":"69315031228"},{"Id":413237,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"69315031820"},{"Id":413238,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"69315031846"},{"Id":413239,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"69315032005"},{"Id":413240,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"69315032010"},{"Id":413241,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"69315032205"},{"Id":413242,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"69315032210"},{"Id":413243,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"69315032505"},{"Id":413244,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"69315032510"},{"Id":413245,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"69315032515"},{"Id":413246,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"69315032705"},{"Id":413247,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"69315032710"},{"Id":413248,"FormularyType":"OHP","DrugName":"GATIFLOXACIN SOL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101029002030","GenericName":"GATIFLOXACIN OPHTH SOLN 0.5%","NDC":"69315033102"},{"Id":413249,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"69315040256"},{"Id":413250,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"69315040356"},{"Id":413251,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"69315040358"},{"Id":413252,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"69315040457"},{"Id":413253,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000307","GenericName":"ALLOPURINOL TAB 200 MG","NDC":"69315040909"},{"Id":413254,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"69315041001"},{"Id":413255,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"69315041005"},{"Id":413256,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"69315050447"},{"Id":413257,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"69315050460"},{"Id":413258,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"69315091001"},{"Id":413259,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"69315091010"},{"Id":413260,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"69339013815"},{"Id":413261,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"69339013817"},{"Id":413262,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"69339013819"},{"Id":413263,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"69339015117"},{"Id":413264,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"69339015119"},{"Id":413265,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"69339015217"},{"Id":413266,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"69339015219"},{"Id":413267,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"69339015301"},{"Id":413268,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 2400/30","DosageForm":"SUSP - Suspension","Strength":"2400","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"69339015317"},{"Id":413269,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"69339015705"},{"Id":413270,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 500/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"69339015717"},{"Id":413271,"FormularyType":"OHP","DrugName":"ITRACONAZOLE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407035002020","GenericName":"ITRACONAZOLE ORAL SOLN 10 MG/ML","NDC":"69339015901"},{"Id":413272,"FormularyType":"OHP","DrugName":"ITRACONAZOLE SOL 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407035002020","GenericName":"ITRACONAZOLE ORAL SOLN 10 MG/ML","NDC":"69339015917"},{"Id":413273,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"69339016016"},{"Id":413274,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"69339016017"},{"Id":413275,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"69339016018"},{"Id":413276,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 400MG/10","DosageForm":"SUSP - Suspension","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"69339016019"},{"Id":413277,"FormularyType":"OHP","DrugName":"GEFITINIB TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360030000320","GenericName":"GEFITINIB TAB 250 MG","NDC":"69339016803"},{"Id":413278,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"69339017101"},{"Id":413279,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"69339017103"},{"Id":413280,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050310","GenericName":"ONDANSETRON HCL TAB 4 MG","NDC":"69339017105"},{"Id":413281,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"69339017201"},{"Id":413282,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065050320","GenericName":"ONDANSETRON HCL TAB 8 MG","NDC":"69339017203"},{"Id":413283,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"69339017301"},{"Id":413284,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"69339017401"},{"Id":413285,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"69339017402"},{"Id":413286,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"69339017441"},{"Id":413287,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"69339017501"},{"Id":413288,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"69339020917"},{"Id":413289,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"69339020919"},{"Id":413290,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"69367013701"},{"Id":413291,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"69367013705"},{"Id":413292,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"69367013801"},{"Id":413293,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"69367013805"},{"Id":413294,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000319","GenericName":"FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)","NDC":"69367016504"},{"Id":413295,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000319","GenericName":"FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)","NDC":"69367016507"},{"Id":413296,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"69367016604"},{"Id":413297,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"69367016607"},{"Id":413298,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"69367016620"},{"Id":413299,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"69367018001"},{"Id":413300,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"69367018005"},{"Id":413301,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"69367018010"},{"Id":413302,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"69367018101"},{"Id":413303,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"69367018105"},{"Id":413304,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"69367018201"},{"Id":413305,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"69367018205"},{"Id":413306,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"69367018210"},{"Id":413307,"FormularyType":"OHP","DrugName":"PNV 27-CA/FE TAB /FA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000360","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG***","NDC":"69367019301"},{"Id":413308,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"69367020005"},{"Id":413309,"FormularyType":"OHP","DrugName":"IRON COMPLEX CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"69367021001"},{"Id":413310,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"69367021101"},{"Id":413311,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"69367021110"},{"Id":413312,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"69367021201"},{"Id":413313,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"69367021210"},{"Id":413314,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"69367021301"},{"Id":413315,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"69367021310"},{"Id":413316,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"69367021401"},{"Id":413317,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"69367021410"},{"Id":413318,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"69367021901"},{"Id":413319,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"69367021905"},{"Id":413320,"FormularyType":"OHP","DrugName":"HYDROCHLOROT CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000110","GenericName":"HYDROCHLOROTHIAZIDE CAP 12.5 MG","NDC":"69367021910"},{"Id":413321,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"69367024101"},{"Id":413322,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"69367024105"},{"Id":413323,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"69367024201"},{"Id":413324,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"69367024205"},{"Id":413325,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"69367024806"},{"Id":413326,"FormularyType":"OHP","DrugName":"WESNATAL DHA PAK COMPLETE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78515022006315","GenericName":"*PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 200 PK**","NDC":"69367025130"},{"Id":413327,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"69367025405"},{"Id":413328,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"69367025409"},{"Id":413329,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"69367025810"},{"Id":413330,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"69367026209"},{"Id":413331,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"69367026230"},{"Id":413332,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"69367026309"},{"Id":413333,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"69367026330"},{"Id":413334,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 2.5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007505","GenericName":"FELODIPINE TAB ER 24HR 2.5 MG","NDC":"69367026401"},{"Id":413335,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007510","GenericName":"FELODIPINE TAB ER 24HR 5 MG","NDC":"69367026501"},{"Id":413336,"FormularyType":"OHP","DrugName":"FELODIPINE TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000013007520","GenericName":"FELODIPINE TAB ER 24HR 10 MG","NDC":"69367026601"},{"Id":413337,"FormularyType":"OHP","DrugName":"WESTAB PLUS TAB 27-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"69367026701"},{"Id":413338,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"69367027102"},{"Id":413339,"FormularyType":"OHP","DrugName":"ERGOCALCIFER DRO 8000/ML","DosageForm":"SOLN - Solution","Strength":"8000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030002030","GenericName":"ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML)","NDC":"69367028302"},{"Id":413340,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"69367028705"},{"Id":413341,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"69367028709"},{"Id":413342,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"69367029360"},{"Id":413343,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"69367029460"},{"Id":413344,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"69367029820"},{"Id":413345,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69367030101"},{"Id":413346,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69367030105"},{"Id":413347,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69367030201"},{"Id":413348,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69367030205"},{"Id":413349,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"69367030709"},{"Id":413350,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000320","GenericName":"EPLERENONE TAB 25 MG","NDC":"69367030730"},{"Id":413351,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"69367030809"},{"Id":413352,"FormularyType":"OHP","DrugName":"EPLERENONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36250030000330","GenericName":"EPLERENONE TAB 50 MG","NDC":"69367030830"},{"Id":413353,"FormularyType":"OHP","DrugName":"SODIUM FLUOR CRE 5000 PPM","DosageForm":"CREA - Cream","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020003721","GenericName":"SODIUM FLUORIDE CREAM 1.1%","NDC":"69367030951"},{"Id":413354,"FormularyType":"OHP","DrugName":"SODIUM FLUOR GEL 1.1%","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"69367031056"},{"Id":413355,"FormularyType":"OHP","DrugName":"SODIUM FLUOR PST 5000 PPM","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"69367031101"},{"Id":413356,"FormularyType":"OHP","DrugName":"SODIUM FLUOR PST 5000 PPM","DosageForm":"PSTE - Paste","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004418","GenericName":"SODIUM FLUORIDE PASTE 1.1%","NDC":"69367031201"},{"Id":413357,"FormularyType":"OHP","DrugName":"WESCAPS CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000130","GenericName":"*B-COMPLEX W/ C & FOLIC ACID CAP 1 MG***","NDC":"69367031401"},{"Id":413358,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"69367032304"},{"Id":413359,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"69367032316"},{"Id":413360,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"69367032409"},{"Id":413361,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"69367032509"},{"Id":413362,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"69367032609"},{"Id":413363,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"69367032709"},{"Id":413364,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"69367032809"},{"Id":413365,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"69367032909"},{"Id":413366,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"69367033009"},{"Id":413367,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"69367033109"},{"Id":413368,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007520","GenericName":"LEVETIRACETAM TAB ER 24HR 500 MG","NDC":"69367033260"},{"Id":413369,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"69367033360"},{"Id":413370,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"69367033801"},{"Id":413371,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"69367033805"},{"Id":413372,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"69367033901"},{"Id":413373,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"69367033905"},{"Id":413374,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"69367033910"},{"Id":413375,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"69367034001"},{"Id":413376,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"69367034005"},{"Id":413377,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"69367034305"},{"Id":413378,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"69367034405"},{"Id":413379,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"69367034505"},{"Id":413380,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"69367034605"},{"Id":413381,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"69367034705"},{"Id":413382,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"69367034860"},{"Id":413383,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"69367034960"},{"Id":413384,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"69367035060"},{"Id":413385,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"69367035160"},{"Id":413386,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"69367035210"},{"Id":413387,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"69367035220"},{"Id":413388,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"69367035601"},{"Id":413389,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"69367035716"},{"Id":413390,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"69367035905"},{"Id":413391,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"69367035909"},{"Id":413392,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"69367035910"},{"Id":413393,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"69367036005"},{"Id":413394,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"69367036009"},{"Id":413395,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"69367036010"},{"Id":413396,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"69367036105"},{"Id":413397,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"69367036109"},{"Id":413398,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"69367036110"},{"Id":413399,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"69367036205"},{"Id":413400,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"69367036209"},{"Id":413401,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"69367036230"},{"Id":413402,"FormularyType":"OHP","DrugName":"PHENOBARB ELX 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"69367036716"},{"Id":413403,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"69367037409"},{"Id":413404,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"69367037410"},{"Id":413405,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"69367037509"},{"Id":413406,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"69367037510"},{"Id":413407,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"69367037609"},{"Id":413408,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"69367037610"},{"Id":413409,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"69367037709"},{"Id":413410,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"69367037710"},{"Id":413411,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"69367037801"},{"Id":413412,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"69367037830"},{"Id":413413,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"69367037901"},{"Id":413414,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"69367037930"},{"Id":413415,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"69367038101"},{"Id":413416,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"69367038105"},{"Id":413417,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"69367038110"},{"Id":413418,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"69367038201"},{"Id":413419,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"69367038205"},{"Id":413420,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"69367038210"},{"Id":413421,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"69367038301"},{"Id":413422,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"69367038305"},{"Id":413423,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"69367038310"},{"Id":413424,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100310","GenericName":"CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","NDC":"69367038501"},{"Id":413425,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"69367038601"},{"Id":413426,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100315","GenericName":"CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","NDC":"69367038605"},{"Id":413427,"FormularyType":"OHP","DrugName":"CIPROFLOXACN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000020100320","GenericName":"CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","NDC":"69367038750"},{"Id":413428,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"69367039401"},{"Id":413429,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"69367039405"},{"Id":413430,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"69367039501"},{"Id":413431,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"69367039505"},{"Id":413432,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"69367039601"},{"Id":413433,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"69367039605"},{"Id":413434,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"69367040010"},{"Id":413435,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"69367040110"},{"Id":413436,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"69367040216"},{"Id":413437,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"69367040901"},{"Id":413438,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"69367040930"},{"Id":413439,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"69367041001"},{"Id":413440,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"69367041030"},{"Id":413441,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"69367041102"},{"Id":413442,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 400MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007540","GenericName":"THEOPHYLLINE TAB ER 24HR 400 MG","NDC":"69367041401"},{"Id":413443,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 600MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007560","GenericName":"THEOPHYLLINE TAB ER 24HR 600 MG","NDC":"69367041501"},{"Id":413444,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000305","GenericName":"PINDOLOL TAB 5 MG","NDC":"69367042101"},{"Id":413445,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000310","GenericName":"PINDOLOL TAB 10 MG","NDC":"69367042201"},{"Id":413446,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"69367042327"},{"Id":413447,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"69367042405"},{"Id":413448,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"69367042409"},{"Id":413449,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"69367042505"},{"Id":413450,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"69367042509"},{"Id":413451,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"69367042605"},{"Id":413452,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"69367042609"},{"Id":413453,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"69367042705"},{"Id":413454,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"69367042709"},{"Id":413455,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"69367042805"},{"Id":413456,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"69367042809"},{"Id":413457,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"69367042905"},{"Id":413458,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"69367042909"},{"Id":413459,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"69367043009"},{"Id":413460,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"69367043105"},{"Id":413461,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"69367043109"},{"Id":413462,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100305","GenericName":"PHENAZOPYRIDINE HCL TAB 100 MG","NDC":"69367061101"},{"Id":413463,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100310","GenericName":"PHENAZOPYRIDINE HCL TAB 200 MG","NDC":"69367061201"},{"Id":413464,"FormularyType":"OHP","DrugName":"SALSALATE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000305","GenericName":"SALSALATE TAB 500 MG","NDC":"69367061501"},{"Id":413465,"FormularyType":"OHP","DrugName":"SALSALATE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100075000310","GenericName":"SALSALATE TAB 750 MG","NDC":"69367061601"},{"Id":413466,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"69367062501"},{"Id":413467,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"69367062510"},{"Id":413468,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"69367062601"},{"Id":413469,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"69367062610"},{"Id":413470,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"69367062701"},{"Id":413471,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"69367062710"},{"Id":413472,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"69367062801"},{"Id":413473,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"69367062810"},{"Id":413474,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"69367067701"},{"Id":413475,"FormularyType":"OHP","DrugName":"HYOSCYAMINE SUB 0.125MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100710","GenericName":"HYOSCYAMINE SULFATE SL TAB 0.125 MG","NDC":"69367067801"},{"Id":413476,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107220","GenericName":"HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","NDC":"69367067901"},{"Id":413477,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"69367069101"},{"Id":413478,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"69367069105"},{"Id":413479,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"69367069201"},{"Id":413480,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"69367069205"},{"Id":413481,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"69367069301"},{"Id":413482,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"69367069305"},{"Id":413483,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"69367069401"},{"Id":413484,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"69367069405"},{"Id":413485,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"69374021450"},{"Id":413486,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"69374091450"},{"Id":413487,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"69375000310"},{"Id":413488,"FormularyType":"OHP","DrugName":"CAPSAICIN HP CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"69375000660"},{"Id":413489,"FormularyType":"OHP","DrugName":"B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"69375000710"},{"Id":413490,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000319","GenericName":"FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)","NDC":"69375000910"},{"Id":413491,"FormularyType":"OHP","DrugName":"B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"69375001310"},{"Id":413492,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"69375001495"},{"Id":413493,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 1 MCG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000110","GenericName":"PARICALCITOL CAP 1 MCG","NDC":"69387010330"},{"Id":413494,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 2 MCG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000120","GenericName":"PARICALCITOL CAP 2 MCG","NDC":"69387010430"},{"Id":413495,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"69396000105"},{"Id":413496,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"69396000120"},{"Id":413497,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"69396000205"},{"Id":413498,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"69396000220"},{"Id":413499,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"69396000320"},{"Id":413500,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"69396000820"},{"Id":413501,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"69396001420"},{"Id":413502,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"69396001505"},{"Id":413503,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"69396002102"},{"Id":413504,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"69396002154"},{"Id":413505,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"69396002701"},{"Id":413506,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"69396002801"},{"Id":413507,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"69396005001"},{"Id":413508,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"69399018381"},{"Id":413509,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69399018481"},{"Id":413510,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69399018485"},{"Id":413511,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"69399019485"},{"Id":413512,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"69420602501"},{"Id":413513,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.025%","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"69420602505"},{"Id":413514,"FormularyType":"OHP","DrugName":"CAMCEVI INJ 42MG","DosageForm":"PRSY - Prefilled Syr","Strength":"42","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2140501055E420","GenericName":"LEUPROLIDE MESYLATE (6 MONTH) EMULSION PREFILLED SYR 42 MG","NDC":"69448001463"},{"Id":413515,"FormularyType":"OHP","DrugName":"CAMCEVI INJ 42MG","DosageForm":"PRSY - Prefilled Syr","Strength":"42","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2140501055E420","GenericName":"LEUPROLIDE MESYLATE (6 MONTH) EMULSION PREFILLED SYR 42 MG","NDC":"69448002363"},{"Id":413516,"FormularyType":"OHP","DrugName":"CLOBAZAM SUS 2.5MG/ML","DosageForm":"SUSP - Suspension","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007001830","GenericName":"CLOBAZAM SUSPENSION 2.5 MG/ML","NDC":"69452011645"},{"Id":413517,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"69452011721"},{"Id":413518,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"69452011821"},{"Id":413519,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"69452012550"},{"Id":413520,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"69452012619"},{"Id":413521,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"69452012660"},{"Id":413522,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"69452012719"},{"Id":413523,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 2.4GM","DosageForm":"PACK - Packet","Strength":"2.4","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053040","GenericName":"SEVELAMER CARBONATE PACKET 2.4 GM","NDC":"69452012760"},{"Id":413524,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"69452013117"},{"Id":413525,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"69452013217"},{"Id":413526,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"69452013317"},{"Id":413527,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"69452014220"},{"Id":413528,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"69452014230"},{"Id":413529,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"69452014320"},{"Id":413530,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"69452014330"},{"Id":413531,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"69452014420"},{"Id":413532,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"69452014430"},{"Id":413533,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 1 MCG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000110","GenericName":"PARICALCITOL CAP 1 MCG","NDC":"69452014513"},{"Id":413534,"FormularyType":"OHP","DrugName":"PARICALCITOL CAP 2 MCG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905070000120","GenericName":"PARICALCITOL CAP 2 MCG","NDC":"69452014613"},{"Id":413535,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030000110","GenericName":"ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"69452015120"},{"Id":413536,"FormularyType":"OHP","DrugName":"ETHOSUXIMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400010000105","GenericName":"ETHOSUXIMIDE CAP 250 MG","NDC":"69452015220"},{"Id":413537,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"69452015673"},{"Id":413538,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107220","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","NDC":"69452015674"},{"Id":413539,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"69452015773"},{"Id":413540,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060107230","GenericName":"RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","NDC":"69452015774"},{"Id":413541,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 125MG","DosageForm":"TBSO - Tablet Soluble","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007320","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 125 MG","NDC":"69452015913"},{"Id":413542,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 250MG","DosageForm":"TBSO - Tablet Soluble","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007330","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 250 MG","NDC":"69452016013"},{"Id":413543,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 500MG","DosageForm":"TBSO - Tablet Soluble","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025007340","GenericName":"DEFERASIROX TAB FOR ORAL SUSP 500 MG","NDC":"69452016113"},{"Id":413544,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"69452017104"},{"Id":413545,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"69452017113"},{"Id":413546,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000320","GenericName":"AZITHROMYCIN TAB 250 MG","NDC":"69452017173"},{"Id":413547,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"69452017213"},{"Id":413548,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"69452017272"},{"Id":413549,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000334","GenericName":"AZITHROMYCIN TAB 500 MG","NDC":"69452017274"},{"Id":413550,"FormularyType":"OHP","DrugName":"AZITHROMYCIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010000340","GenericName":"AZITHROMYCIN TAB 600 MG","NDC":"69452017313"},{"Id":413551,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100320","GenericName":"IVABRADINE HCL TAB 5 MG (BASE EQUIV)","NDC":"69452019017"},{"Id":413552,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100330","GenericName":"IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","NDC":"69452019117"},{"Id":413553,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"69452020713"},{"Id":413554,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.25MCG","DosageForm":"CAPS - Capsule","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000105","GenericName":"CALCITRIOL CAP 0.25 MCG","NDC":"69452020720"},{"Id":413555,"FormularyType":"OHP","DrugName":"CALCITRIOL CAP 0.5MCG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905030000110","GenericName":"CALCITRIOL CAP 0.5 MCG","NDC":"69452020820"},{"Id":413556,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"69452023320"},{"Id":413557,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"69452023420"},{"Id":413558,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100310","GenericName":"TRIHEXYPHENIDYL HCL TAB 2 MG","NDC":"69452024120"},{"Id":413559,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100320","GenericName":"TRIHEXYPHENIDYL HCL TAB 5 MG","NDC":"69452024220"},{"Id":413560,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"69452025287"},{"Id":413561,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000320","GenericName":"ETRAVIRINE TAB 100 MG","NDC":"69452025422"},{"Id":413562,"FormularyType":"OHP","DrugName":"ETRAVIRINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109035000340","GenericName":"ETRAVIRINE TAB 200 MG","NDC":"69452025517"},{"Id":413563,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"69452026720"},{"Id":413564,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"69452027120"},{"Id":413565,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"69452027130"},{"Id":413566,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"69452027620"},{"Id":413567,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"69452027720"},{"Id":413568,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"69452027820"},{"Id":413569,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"69452029020"},{"Id":413570,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"69452029030"},{"Id":413571,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"69452029120"},{"Id":413572,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"69452029130"},{"Id":413573,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"69452031120"},{"Id":413574,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"69452031132"},{"Id":413575,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"69452031220"},{"Id":413576,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"69452031232"},{"Id":413577,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"69452032320"},{"Id":413578,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000310","GenericName":"CIMETIDINE TAB 300 MG","NDC":"69452032420"},{"Id":413579,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000315","GenericName":"CIMETIDINE TAB 400 MG","NDC":"69452032520"},{"Id":413580,"FormularyType":"OHP","DrugName":"CIMETIDINE TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000320","GenericName":"CIMETIDINE TAB 800 MG","NDC":"69452032620"},{"Id":413581,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"69452032820"},{"Id":413582,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"69452032920"},{"Id":413583,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100105","GenericName":"TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","NDC":"69452033020"},{"Id":413584,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"69452033120"},{"Id":413585,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100110","GenericName":"TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","NDC":"69452033132"},{"Id":413586,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"69452033220"},{"Id":413587,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100115","GenericName":"TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","NDC":"69452033232"},{"Id":413588,"FormularyType":"OHP","DrugName":"TERAZOSIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202040100120","GenericName":"TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","NDC":"69452033320"},{"Id":413589,"FormularyType":"OHP","DrugName":"NARATRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406050100320","GenericName":"NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV)","NDC":"69452034172"},{"Id":413590,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"69452034460"},{"Id":413591,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100305","GenericName":"SUMATRIPTAN SUCCINATE TAB 25 MG","NDC":"69452034472"},{"Id":413592,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"69452034560"},{"Id":413593,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100310","GenericName":"SUMATRIPTAN SUCCINATE TAB 50 MG","NDC":"69452034572"},{"Id":413594,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"69452034660"},{"Id":413595,"FormularyType":"OHP","DrugName":"SUMATRIPTAN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070100320","GenericName":"SUMATRIPTAN SUCCINATE TAB 100 MG","NDC":"69452034672"},{"Id":413596,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000320","GenericName":"ESZOPICLONE TAB 1 MG","NDC":"69452034713"},{"Id":413597,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000330","GenericName":"ESZOPICLONE TAB 2 MG","NDC":"69452034820"},{"Id":413598,"FormularyType":"OHP","DrugName":"ESZOPICLONE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204035000340","GenericName":"ESZOPICLONE TAB 3 MG","NDC":"69452034920"},{"Id":413599,"FormularyType":"OHP","DrugName":"GRANISETRON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035100310","GenericName":"GRANISETRON HCL TAB 1 MG","NDC":"69452035001"},{"Id":413600,"FormularyType":"OHP","DrugName":"GRANISETRON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035100310","GenericName":"GRANISETRON HCL TAB 1 MG","NDC":"69452035011"},{"Id":413601,"FormularyType":"OHP","DrugName":"GRANISETRON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250035100310","GenericName":"GRANISETRON HCL TAB 1 MG","NDC":"69452035092"},{"Id":413602,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"69452035113"},{"Id":413603,"FormularyType":"OHP","DrugName":"TERBINAFINE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11000080100310","GenericName":"TERBINAFINE HCL TAB 250 MG","NDC":"69452035120"},{"Id":413604,"FormularyType":"OHP","DrugName":"ACAMPRO CAL TAB 333MG","DosageForm":"TBEC - Tablet DR","Strength":"333","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"AGENTS FOR CHEMICAL DEPENDENCY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62802010200620","GenericName":"ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","NDC":"69452035325"},{"Id":413605,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100310","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","NDC":"69452035620"},{"Id":413606,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100315","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","NDC":"69452035720"},{"Id":413607,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100320","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 1 MG","NDC":"69452035820"},{"Id":413608,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100330","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 2 MG","NDC":"69452035920"},{"Id":413609,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100337","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 3 MG","NDC":"69452036020"},{"Id":413610,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100344","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 4 MG","NDC":"69452036120"},{"Id":413611,"FormularyType":"OHP","DrugName":"ROPINIROLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73203070100350","GenericName":"ROPINIROLE HYDROCHLORIDE TAB 5 MG","NDC":"69452036220"},{"Id":413612,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000120","GenericName":"ZALEPLON CAP 5 MG","NDC":"69452036420"},{"Id":413613,"FormularyType":"OHP","DrugName":"ZALEPLON CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204070000130","GenericName":"ZALEPLON CAP 10 MG","NDC":"69452036520"},{"Id":413614,"FormularyType":"OHP","DrugName":"IBANDRONATE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042048100360","GenericName":"IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"69452037874"},{"Id":413615,"FormularyType":"OHP","DrugName":"HYDROXYZINE SOL 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"69452039588"},{"Id":413616,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"69452041288"},{"Id":413617,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"69452042655"},{"Id":413618,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"69452042688"},{"Id":413619,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69452047120"},{"Id":413620,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69452047220"},{"Id":413621,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"69499033060"},{"Id":413622,"FormularyType":"OHP","DrugName":"AFTERA TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"69536010388"},{"Id":413623,"FormularyType":"OHP","DrugName":"PLAN B TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"69536014619"},{"Id":413624,"FormularyType":"OHP","DrugName":"PLAN B TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"69536016288"},{"Id":413625,"FormularyType":"OHP","DrugName":"ST JOSEPH TAB LOW 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"69536018112"},{"Id":413626,"FormularyType":"OHP","DrugName":"TAKE ACTION TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"69536020088"},{"Id":413627,"FormularyType":"OHP","DrugName":"ST JOSEPH CHW LOW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"69536028110"},{"Id":413628,"FormularyType":"OHP","DrugName":"ST JOSEPH CHW LOW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"69536028136"},{"Id":413629,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"69543045510"},{"Id":413630,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"69543045520"},{"Id":413631,"FormularyType":"OHP","DrugName":"NARCAN SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"69547062702"},{"Id":413632,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"69584002109"},{"Id":413633,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"69584002150"},{"Id":413634,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"69584002190"},{"Id":413635,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69584002209"},{"Id":413636,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69584002250"},{"Id":413637,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69584002290"},{"Id":413638,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"69584002295"},{"Id":413639,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69584002309"},{"Id":413640,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69584002350"},{"Id":413641,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69584002390"},{"Id":413642,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"69584002393"},{"Id":413643,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"69584030910"},{"Id":413644,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"69584030950"},{"Id":413645,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"69584030990"},{"Id":413646,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"69584031010"},{"Id":413647,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"69584031050"},{"Id":413648,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"69584031090"},{"Id":413649,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"69584036110"},{"Id":413650,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"69584036190"},{"Id":413651,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000305","GenericName":"HYDROCHLOROTHIAZIDE TAB 25 MG","NDC":"69584036195"},{"Id":413652,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"69584036210"},{"Id":413653,"FormularyType":"OHP","DrugName":"HYDROCHLOROT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600040000310","GenericName":"HYDROCHLOROTHIAZIDE TAB 50 MG","NDC":"69584036290"},{"Id":413654,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"69584061110"},{"Id":413655,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"69584061150"},{"Id":413656,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"69584061190"},{"Id":413657,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"69584061210"},{"Id":413658,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"69584061250"},{"Id":413659,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"69584061290"},{"Id":413660,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"69584068410"},{"Id":413661,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"69584068450"},{"Id":413662,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"69584068510"},{"Id":413663,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"69584068550"},{"Id":413664,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"69584084110"},{"Id":413665,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"69584084150"},{"Id":413666,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"69584084210"},{"Id":413667,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"69584084230"},{"Id":413668,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100320","GenericName":"SOTALOL HCL TAB 160 MG","NDC":"69584084310"},{"Id":413669,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 240MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100330","GenericName":"SOTALOL HCL TAB 240 MG","NDC":"69584084410"},{"Id":413670,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"69584085210"},{"Id":413671,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"69584085250"},{"Id":413672,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"69584085290"},{"Id":413673,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"69584085292"},{"Id":413674,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"69584085310"},{"Id":413675,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"69584085350"},{"Id":413676,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"69584085390"},{"Id":413677,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"69584085410"},{"Id":413678,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"69584085450"},{"Id":413679,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"69584085490"},{"Id":413680,"FormularyType":"OHP","DrugName":"RENAL VITAMN TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"69618000701"},{"Id":413681,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"69618000901"},{"Id":413682,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"69618001001"},{"Id":413683,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"69618001101"},{"Id":413684,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"69618001501"},{"Id":413685,"FormularyType":"OHP","DrugName":"VITAMIN D DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"69618001959"},{"Id":413686,"FormularyType":"OHP","DrugName":"CALCIUM CARB CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"69618002015"},{"Id":413687,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"69618002302"},{"Id":413688,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"69618002401"},{"Id":413689,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"69618002501"},{"Id":413690,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"69618002601"},{"Id":413691,"FormularyType":"OHP","DrugName":"MECLIZINE CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"69618002801"},{"Id":413692,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 10GR","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"69618003410"},{"Id":413693,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"69618003701"},{"Id":413694,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"69618003806"},{"Id":413695,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"69618004201"},{"Id":413696,"FormularyType":"OHP","DrugName":"POLY-VITA DRO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"69618006259"},{"Id":413697,"FormularyType":"OHP","DrugName":"POLY-VITA/FE DRO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002010","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**","NDC":"69618006359"},{"Id":413698,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"69618006401"},{"Id":413699,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"69618006501"},{"Id":413700,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"69618006602"},{"Id":413701,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"69618006610"},{"Id":413702,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"69618006958"},{"Id":413703,"FormularyType":"OHP","DrugName":"IRON SUPPLMT DRO 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"69618007059"},{"Id":413704,"FormularyType":"OHP","DrugName":"B12 LIQ 1000/15","DosageForm":"LIQD - Liquid","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000945","GenericName":"CYANOCOBALAMIN LIQUID 1000 MCG/15ML","NDC":"69618007158"},{"Id":413705,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"69618007342"},{"Id":413706,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"69618007854"},{"Id":413707,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"69618008401"},{"Id":413708,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"69618008601"},{"Id":413709,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680011210"},{"Id":413710,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680011225"},{"Id":413711,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680011310"},{"Id":413712,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680011399"},{"Id":413713,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680012105"},{"Id":413714,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680012110"},{"Id":413715,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"69680012130"},{"Id":413716,"FormularyType":"OHP","DrugName":"THYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"69680016500"},{"Id":413717,"FormularyType":"OHP","DrugName":"THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"69680016600"},{"Id":413718,"FormularyType":"OHP","DrugName":"THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"69680016700"},{"Id":413719,"FormularyType":"OHP","DrugName":"THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"69680016800"},{"Id":413720,"FormularyType":"OHP","DrugName":"THYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"69680016900"},{"Id":413721,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"69680018692"},{"Id":413722,"FormularyType":"OHP","DrugName":"DOJOLVI LIQ 100%","DosageForm":"LIQD - Liquid","Strength":"100","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"LIPIDS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80200080000920","GenericName":"TRIHEPTANOIN ORAL LIQUID 100%","NDC":"69794005050"},{"Id":413723,"FormularyType":"OHP","DrugName":"THRIVACIN 30 LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"69800000020"},{"Id":413724,"FormularyType":"OHP","DrugName":"THRIVACIN LIQ DETOX","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"69800000021"},{"Id":413725,"FormularyType":"OHP","DrugName":"SURE RESULT CRE SR 0.025","DosageForm":"CREA - Cream","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003710","GenericName":"CAPSAICIN CREAM 0.025%","NDC":"69837051010"},{"Id":413726,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"69842000101"},{"Id":413727,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"69842002415"},{"Id":413728,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"69842002416"},{"Id":413729,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842002515"},{"Id":413730,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842002544"},{"Id":413731,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"69842003735"},{"Id":413732,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"69842003744"},{"Id":413733,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"69842006200"},{"Id":413734,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"69842006319"},{"Id":413735,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"69842008503"},{"Id":413736,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"69842008509"},{"Id":413737,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"69842008805"},{"Id":413738,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"69842008816"},{"Id":413739,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"69842008952"},{"Id":413740,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"69842019257"},{"Id":413741,"FormularyType":"OHP","DrugName":"CVS LAXATIVE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"69842019509"},{"Id":413742,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"69842019916"},{"Id":413743,"FormularyType":"OHP","DrugName":"ANTIBIOTIC OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"69842019958"},{"Id":413744,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842021715"},{"Id":413745,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842021716"},{"Id":413746,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842021744"},{"Id":413747,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"69842023723"},{"Id":413748,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"69842023739"},{"Id":413749,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69842024239"},{"Id":413750,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69842024291"},{"Id":413751,"FormularyType":"OHP","DrugName":"CVS OLOPATAD SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"69842026805"},{"Id":413752,"FormularyType":"OHP","DrugName":"CVS OLOPATAD SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"69842026925"},{"Id":413753,"FormularyType":"OHP","DrugName":"CVS OLOPATAD SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"69842026950"},{"Id":413754,"FormularyType":"OHP","DrugName":"8HR PAIN ER TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"69842031278"},{"Id":413755,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"69842032967"},{"Id":413756,"FormularyType":"OHP","DrugName":"CVS ALLERGY SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"69842033726"},{"Id":413757,"FormularyType":"OHP","DrugName":"CVS ALLERGY SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"69842033734"},{"Id":413758,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842043016"},{"Id":413759,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"69842048462"},{"Id":413760,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"69842048471"},{"Id":413761,"FormularyType":"OHP","DrugName":"CVS ANTIBIOT OIN 1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"69842050158"},{"Id":413762,"FormularyType":"OHP","DrugName":"CVS ANTIBIOT OIN 1%","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"69842050164"},{"Id":413763,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"69842058620"},{"Id":413764,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"69842058680"},{"Id":413765,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"69842059123"},{"Id":413766,"FormularyType":"OHP","DrugName":"CVS HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"69842059180"},{"Id":413767,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"69842060815"},{"Id":413768,"FormularyType":"OHP","DrugName":"CVS NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"69842060915"},{"Id":413769,"FormularyType":"OHP","DrugName":"CVS PINWORM SUS 50MG/ML","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"69842061802"},{"Id":413770,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"69842070301"},{"Id":413771,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"69842070662"},{"Id":413772,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"69842072902"},{"Id":413773,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69842074502"},{"Id":413774,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69842074520"},{"Id":413775,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"69842074560"},{"Id":413776,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"69842078025"},{"Id":413777,"FormularyType":"OHP","DrugName":"CVS OMEPRAZO TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"69842079155"},{"Id":413778,"FormularyType":"OHP","DrugName":"CVS OMEPRAZO TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"69842079174"},{"Id":413779,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"69842086225"},{"Id":413780,"FormularyType":"OHP","DrugName":"CVS ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"69842087651"},{"Id":413781,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"69842088710"},{"Id":413782,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"69842093108"},{"Id":413783,"FormularyType":"OHP","DrugName":"CVS ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"69842096801"},{"Id":413784,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"69842097417"},{"Id":413785,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"69842097435"},{"Id":413786,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"69842097453"},{"Id":413787,"FormularyType":"OHP","DrugName":"ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"69848000609"},{"Id":413788,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"69848001510"},{"Id":413789,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"69848001910"},{"Id":413790,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100310","GenericName":"DESMOPRESSIN ACETATE TAB 0.1 MG","NDC":"69918010101"},{"Id":413791,"FormularyType":"OHP","DrugName":"DESMOPRESSIN TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010100320","GenericName":"DESMOPRESSIN ACETATE TAB 0.2 MG","NDC":"69918020101"},{"Id":413792,"FormularyType":"OHP","DrugName":"TRANEX ACID TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"HEMOSTATICS","DrugSubClass":"HEMOSTATICS - SYSTEMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"84100040000320","GenericName":"TRANEXAMIC ACID TAB 650 MG","NDC":"69918030130"},{"Id":413793,"FormularyType":"OHP","DrugName":"NEO/POLY/DEX SUS 0.1% OP","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86309903321810","GenericName":"NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%","NDC":"69918051505"},{"Id":413794,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"69918056030"},{"Id":413795,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"69918089901"},{"Id":413796,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"69918089902"},{"Id":413797,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"69918089910"},{"Id":413798,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"69918089911"},{"Id":413799,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"69918090110"},{"Id":413800,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"69918090111"},{"Id":413801,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"69918090112"},{"Id":413802,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"69967000801"},{"Id":413803,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"69967000803"},{"Id":413804,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"69967000901"},{"Id":413805,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"69967000902"},{"Id":413806,"FormularyType":"OHP","DrugName":"CLEARDETECT KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"69978000004"},{"Id":413807,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"70000000201"},{"Id":413808,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"70000000202"},{"Id":413809,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000000301"},{"Id":413810,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"70000000901"},{"Id":413811,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"70000001401"},{"Id":413812,"FormularyType":"OHP","DrugName":"ALCOHOL WIPE MIS 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"70000002601"},{"Id":413813,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"70000002801"},{"Id":413814,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70000003201"},{"Id":413815,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70000003202"},{"Id":413816,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70000003203"},{"Id":413817,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"70000003501"},{"Id":413818,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000003601"},{"Id":413819,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"70000004801"},{"Id":413820,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70000004901"},{"Id":413821,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH REL","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"70000005301"},{"Id":413822,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH/RED","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"70000005401"},{"Id":413823,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"70000006101"},{"Id":413824,"FormularyType":"OHP","DrugName":"ANTACID SUS MINT","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"70000006301"},{"Id":413825,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"70000006501"},{"Id":413826,"FormularyType":"OHP","DrugName":"HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70000006601"},{"Id":413827,"FormularyType":"OHP","DrugName":"FIBR LAX+CAL TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"70000006701"},{"Id":413828,"FormularyType":"OHP","DrugName":"LAXATIVE MAX TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"70000007701"},{"Id":413829,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"70000009101"},{"Id":413830,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"70000009102"},{"Id":413831,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"70000009103"},{"Id":413832,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"70000009201"},{"Id":413833,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"70000009401"},{"Id":413834,"FormularyType":"OHP","DrugName":"MOTION SICKN TAB 25 MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"70000009701"},{"Id":413835,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"70000010802"},{"Id":413836,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"70000011201"},{"Id":413837,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"70000012501"},{"Id":413838,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70000013602"},{"Id":413839,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70000013603"},{"Id":413840,"FormularyType":"OHP","DrugName":"HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70000014601"},{"Id":413841,"FormularyType":"OHP","DrugName":"TRI-BUFF ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64109902040320","GenericName":"ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG","NDC":"70000014701"},{"Id":413842,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"70000015701"},{"Id":413843,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"70000015703"},{"Id":413844,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"70000016002"},{"Id":413845,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017501"},{"Id":413846,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017502"},{"Id":413847,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017503"},{"Id":413848,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017505"},{"Id":413849,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017508"},{"Id":413850,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017601"},{"Id":413851,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017604"},{"Id":413852,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000017605"},{"Id":413853,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70000018101"},{"Id":413854,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"70000020401"},{"Id":413855,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70000021301"},{"Id":413856,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70000021303"},{"Id":413857,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70000021304"},{"Id":413858,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70000021306"},{"Id":413859,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"70000021401"},{"Id":413860,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"70000021501"},{"Id":413861,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70000022101"},{"Id":413862,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70000022102"},{"Id":413863,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70000022103"},{"Id":413864,"FormularyType":"OHP","DrugName":"IBUPROFEN JR CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"70000023901"},{"Id":413865,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"70000024401"},{"Id":413866,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70000024701"},{"Id":413867,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70000024702"},{"Id":413868,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"70000025302"},{"Id":413869,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"70000025304"},{"Id":413870,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70000026201"},{"Id":413871,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70000026301"},{"Id":413872,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70000026302"},{"Id":413873,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70000026401"},{"Id":413874,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000029101"},{"Id":413875,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"70000029801"},{"Id":413876,"FormularyType":"OHP","DrugName":"ACETAMIN JR CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"70000030901"},{"Id":413877,"FormularyType":"OHP","DrugName":"ACETAMINOPHE CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"70000031001"},{"Id":413878,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000031202"},{"Id":413879,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"70000032301"},{"Id":413880,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"70000033401"},{"Id":413881,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"70000033801"},{"Id":413882,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"70000034001"},{"Id":413883,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70000034101"},{"Id":413884,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70000034201"},{"Id":413885,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70000034301"},{"Id":413886,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70000034401"},{"Id":413887,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70000034402"},{"Id":413888,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70000034501"},{"Id":413889,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70000034601"},{"Id":413890,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70000034701"},{"Id":413891,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70000034801"},{"Id":413892,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70000034802"},{"Id":413893,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000036101"},{"Id":413894,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000036102"},{"Id":413895,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000036103"},{"Id":413896,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000036104"},{"Id":413897,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000036105"},{"Id":413898,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000037301"},{"Id":413899,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000037302"},{"Id":413900,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000037303"},{"Id":413901,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000037305"},{"Id":413902,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70000038001"},{"Id":413903,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70000038002"},{"Id":413904,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70000038004"},{"Id":413905,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"70000038101"},{"Id":413906,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"70000038102"},{"Id":413907,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"70000040401"},{"Id":413908,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000041001"},{"Id":413909,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70000041002"},{"Id":413910,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70000041501"},{"Id":413911,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70000041502"},{"Id":413912,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70000041503"},{"Id":413913,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"70000041901"},{"Id":413914,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"70000042001"},{"Id":413915,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1GM","DosageForm":"SUPP - Suppository","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005206","GenericName":"GLYCERIN SUPPOS 1 GM","NDC":"70000042901"},{"Id":413916,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000043002"},{"Id":413917,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000043101"},{"Id":413918,"FormularyType":"OHP","DrugName":"LAXATIVE REG TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200315","GenericName":"SENNOSIDES TAB 15 MG","NDC":"70000044301"},{"Id":413919,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"70000044801"},{"Id":413920,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000046001"},{"Id":413921,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"70000047301"},{"Id":413922,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"70000047401"},{"Id":413923,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"70000047501"},{"Id":413924,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"70000047701"},{"Id":413925,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"70000048501"},{"Id":413926,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"70000051001"},{"Id":413927,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"70000051002"},{"Id":413928,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"70000051101"},{"Id":413929,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"70000051102"},{"Id":413930,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"70000051201"},{"Id":413931,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"70000051202"},{"Id":413932,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"70000052001"},{"Id":413933,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"70000052201"},{"Id":413934,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"70000052202"},{"Id":413935,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"70000052601"},{"Id":413936,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"70000052701"},{"Id":413937,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70000053801"},{"Id":413938,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"70000054202"},{"Id":413939,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"70000054701"},{"Id":413940,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"70000054901"},{"Id":413941,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"70000055001"},{"Id":413942,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"70000055501"},{"Id":413943,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"70000055502"},{"Id":413944,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"70000055503"},{"Id":413945,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"70000055901"},{"Id":413946,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINI","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"70000056001"},{"Id":413947,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"70000056101"},{"Id":413948,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"70000056201"},{"Id":413949,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"70000056701"},{"Id":413950,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70000057101"},{"Id":413951,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70000057102"},{"Id":413952,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70000057103"},{"Id":413953,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"70000057201"},{"Id":413954,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"70000057301"},{"Id":413955,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"70000057302"},{"Id":413956,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70000058301"},{"Id":413957,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"70000058401"},{"Id":413958,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"70000058501"},{"Id":413959,"FormularyType":"OHP","DrugName":"12HR ALLERGY TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"70000058601"},{"Id":413960,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000059201"},{"Id":413961,"FormularyType":"OHP","DrugName":"SMOOTH ANTA CHW FRUIT","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000059301"},{"Id":413962,"FormularyType":"OHP","DrugName":"STOMACH RELE TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"70000059401"},{"Id":413963,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000059701"},{"Id":413964,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70000059702"},{"Id":413965,"FormularyType":"OHP","DrugName":"ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"70000059802"},{"Id":413966,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"70000060101"},{"Id":413967,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70000060301"},{"Id":413968,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70000060302"},{"Id":413969,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70000060303"},{"Id":413970,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70000060401"},{"Id":413971,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70000060402"},{"Id":413972,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"70000061001"},{"Id":413973,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"70000061002"},{"Id":413974,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"70000061003"},{"Id":413975,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70000061101"},{"Id":413976,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"70000061601"},{"Id":413977,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"70000062601"},{"Id":413978,"FormularyType":"OHP","DrugName":"8 HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"70000062702"},{"Id":413979,"FormularyType":"OHP","DrugName":"8 HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"70000062703"},{"Id":413980,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"70000063301"},{"Id":413981,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"70000065601"},{"Id":413982,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"70000065901"},{"Id":413983,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"70000066001"},{"Id":413984,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"70000066101"},{"Id":413985,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"70000066201"},{"Id":413986,"FormularyType":"OHP","DrugName":"MINERAL OIL OIL LAXATIVE","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"70000066301"},{"Id":413987,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"70000066602"},{"Id":413988,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"70000067401"},{"Id":413989,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"70000067901"},{"Id":413990,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000068101"},{"Id":413991,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70000068201"},{"Id":413992,"FormularyType":"OHP","DrugName":"ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"70000068301"},{"Id":413993,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"70000069301"},{"Id":413994,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"70000070101"},{"Id":413995,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70000070401"},{"Id":413996,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70000071001"},{"Id":413997,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"70000071601"},{"Id":413998,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"70000071701"},{"Id":413999,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000072502"},{"Id":414000,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70000072503"},{"Id":414001,"FormularyType":"OHP","DrugName":"8HR ARTHRITS TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"70000073301"},{"Id":414002,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"70004092059"},{"Id":414003,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"70004092359"},{"Id":414004,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"70004092444"},{"Id":414005,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142056","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/250ML-0.9%","NDC":"70004092459"},{"Id":414006,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.75/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142076","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.75 GM/500ML-0.9%","NDC":"70004092644"},{"Id":414007,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"70004092844"},{"Id":414008,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"70010000201"},{"Id":414009,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107020","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","NDC":"70010000401"},{"Id":414010,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107030","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","NDC":"70010000501"},{"Id":414011,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107035","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","NDC":"70010000601"},{"Id":414012,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107040","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","NDC":"70010000701"},{"Id":414013,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107045","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","NDC":"70010000801"},{"Id":414014,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107050","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","NDC":"70010000901"},{"Id":414015,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 35MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107055","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","NDC":"70010001001"},{"Id":414016,"FormularyType":"OHP","DrugName":"DEXMETHYLPHE CAP 40MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016107060","GenericName":"DEXMETHYLPHENIDATE HCL CAP ER 24 HR 40 MG","NDC":"70010001101"},{"Id":414017,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"70010002101"},{"Id":414018,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"70010002201"},{"Id":414019,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"70010002205"},{"Id":414020,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"70010002210"},{"Id":414021,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"70010002803"},{"Id":414022,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 5MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107005","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","NDC":"70010002901"},{"Id":414023,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 10MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107010","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","NDC":"70010003001"},{"Id":414024,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 15MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107015","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","NDC":"70010003101"},{"Id":414025,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 20MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107020","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","NDC":"70010003201"},{"Id":414026,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 25MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107025","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","NDC":"70010003301"},{"Id":414027,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR CAP 30MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902107030","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","NDC":"70010003401"},{"Id":414028,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100403","GenericName":"METHYLPHENIDATE HCL TAB ER 10 MG","NDC":"70010004201"},{"Id":414029,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100405","GenericName":"METHYLPHENIDATE HCL TAB ER 20 MG","NDC":"70010004301"},{"Id":414030,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"70010005140"},{"Id":414031,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"70010006301"},{"Id":414032,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"70010006305"},{"Id":414033,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"70010006309"},{"Id":414034,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"70010006310"},{"Id":414035,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"70010006401"},{"Id":414036,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"70010006405"},{"Id":414037,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"70010006409"},{"Id":414038,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"70010006499"},{"Id":414039,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"70010006501"},{"Id":414040,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"70010006505"},{"Id":414041,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"70010006509"},{"Id":414042,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"70010006599"},{"Id":414043,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"70010006601"},{"Id":414044,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"70010006603"},{"Id":414045,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"70010006605"},{"Id":414046,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"70010006610"},{"Id":414047,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"70010006650"},{"Id":414048,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"70010006701"},{"Id":414049,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"70010006703"},{"Id":414050,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"70010006705"},{"Id":414051,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"70010006710"},{"Id":414052,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"70010006750"},{"Id":414053,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"70010006801"},{"Id":414054,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"70010006803"},{"Id":414055,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"70010006805"},{"Id":414056,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"70010006810"},{"Id":414057,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"70010006850"},{"Id":414058,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"70010007244"},{"Id":414059,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"70010007344"},{"Id":414060,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70010008401"},{"Id":414061,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"70010008501"},{"Id":414062,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"70010008601"},{"Id":414063,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"70010010905"},{"Id":414064,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"70010011101"},{"Id":414065,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100307","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","NDC":"70010011201"},{"Id":414066,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"70010011301"},{"Id":414067,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100312","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","NDC":"70010011401"},{"Id":414068,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"70010011501"},{"Id":414069,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"70010011601"},{"Id":414070,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"70010011701"},{"Id":414071,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70010013303"},{"Id":414072,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70010013309"},{"Id":414073,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70010013310"},{"Id":414074,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70010013403"},{"Id":414075,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70010013409"},{"Id":414076,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70010013410"},{"Id":414077,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"70010013501"},{"Id":414078,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"70010013505"},{"Id":414079,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"70010013510"},{"Id":414080,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"70010013601"},{"Id":414081,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"70010013605"},{"Id":414082,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"70010013610"},{"Id":414083,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"70010013701"},{"Id":414084,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"70010013705"},{"Id":414085,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"70010013801"},{"Id":414086,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"70010013805"},{"Id":414087,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"70010013901"},{"Id":414088,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"70010013905"},{"Id":414089,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"70010013910"},{"Id":414090,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 8MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000205","GenericName":"POTASSIUM CHLORIDE CAP ER 8 MEQ","NDC":"70010014701"},{"Id":414091,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"70010014801"},{"Id":414092,"FormularyType":"OHP","DrugName":"POT CHLORIDE CAP 10MEQ ER","DosageForm":"CPCR - Capsule ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000210","GenericName":"POTASSIUM CHLORIDE CAP ER 10 MEQ","NDC":"70010014805"},{"Id":414093,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"70010016001"},{"Id":414094,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70010016101"},{"Id":414095,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70010016105"},{"Id":414096,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70010016110"},{"Id":414097,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70010016201"},{"Id":414098,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70010016234"},{"Id":414099,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70010016303"},{"Id":414100,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70010016305"},{"Id":414101,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70010016309"},{"Id":414102,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"70010019009"},{"Id":414103,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"70010019109"},{"Id":414104,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"70010019110"},{"Id":414105,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100110","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","NDC":"70010020601"},{"Id":414106,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100120","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","NDC":"70010020701"},{"Id":414107,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100130","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","NDC":"70010020801"},{"Id":414108,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100140","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","NDC":"70010020901"},{"Id":414109,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100150","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","NDC":"70010021001"},{"Id":414110,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100160","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","NDC":"70010021101"},{"Id":414111,"FormularyType":"OHP","DrugName":"LISDEXAMFETA CAP 70MG","DosageForm":"CAPS - Capsule","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100025100170","GenericName":"LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","NDC":"70010021201"},{"Id":414112,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"70010022701"},{"Id":414113,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"70010022705"},{"Id":414114,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"70010022801"},{"Id":414115,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"70010022805"},{"Id":414116,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"70010049101"},{"Id":414117,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"70010049105"},{"Id":414118,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"70010049109"},{"Id":414119,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"70010049110"},{"Id":414120,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"70010049201"},{"Id":414121,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"70010049205"},{"Id":414122,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"70010049210"},{"Id":414123,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"70010066801"},{"Id":414124,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"70010066901"},{"Id":414125,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"70010067001"},{"Id":414126,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"70010067201"},{"Id":414127,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"70010067301"},{"Id":414128,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"70010074103"},{"Id":414129,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"70010074109"},{"Id":414130,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"70010074110"},{"Id":414131,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"70010074203"},{"Id":414132,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"70010074209"},{"Id":414133,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"70010074210"},{"Id":414134,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"70010074303"},{"Id":414135,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"70010074309"},{"Id":414136,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"70010074310"},{"Id":414137,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"70010075401"},{"Id":414138,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"70010075405"},{"Id":414139,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"70010077001"},{"Id":414140,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"70010077005"},{"Id":414141,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"70010078001"},{"Id":414142,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"70010078005"},{"Id":414143,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"70010078010"},{"Id":414144,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"70010078101"},{"Id":414145,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"70010078105"},{"Id":414146,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"70010078110"},{"Id":414147,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"70010078201"},{"Id":414148,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"70010078205"},{"Id":414149,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"70010078210"},{"Id":414150,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"70010078301"},{"Id":414151,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"70010078305"},{"Id":414152,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"70010078310"},{"Id":414153,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"70010078612"},{"Id":414154,"FormularyType":"OHP","DrugName":"METHYLERGON TAB 0.2MG","DosageForm":"TABS - Tablet","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OXYTOCICS","DrugSubClass":"OXYTOCICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"29000020100305","GenericName":"METHYLERGONOVINE MALEATE TAB 0.2 MG","NDC":"70010078628"},{"Id":414155,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"70010092601"},{"Id":414156,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"70010092605"},{"Id":414157,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"70010092610"},{"Id":414158,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"70010092701"},{"Id":414159,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"70010092705"},{"Id":414160,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"70010092710"},{"Id":414161,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"70010092801"},{"Id":414162,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"70010092805"},{"Id":414163,"FormularyType":"OHP","DrugName":"EQ CALCIUM TAB CITR+D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"70030011698"},{"Id":414164,"FormularyType":"OHP","DrugName":"FIRST AID OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"70030012515"},{"Id":414165,"FormularyType":"OHP","DrugName":"GOODSENSE SOL ELECTROL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70030012706"},{"Id":414166,"FormularyType":"OHP","DrugName":"GOODSENSE SOL ELECTROL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70030012713"},{"Id":414167,"FormularyType":"OHP","DrugName":"GOODSENSE SOL ELECTROL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70030012714"},{"Id":414168,"FormularyType":"OHP","DrugName":"GOODSENSE SOL ELECTROL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70030012715"},{"Id":414169,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70030012923"},{"Id":414170,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"70030012983"},{"Id":414171,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"70030013012"},{"Id":414172,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"70030013032"},{"Id":414173,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"70030013050"},{"Id":414174,"FormularyType":"OHP","DrugName":"WOMENS LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70030013131"},{"Id":414175,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70030013133"},{"Id":414176,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013135"},{"Id":414177,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013165"},{"Id":414178,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"70030013186"},{"Id":414179,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013207"},{"Id":414180,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"70030013239"},{"Id":414181,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013246"},{"Id":414182,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE TUBE/KIT","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"70030013252"},{"Id":414183,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70030013264"},{"Id":414184,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"70030013422"},{"Id":414185,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013430"},{"Id":414186,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013512"},{"Id":414187,"FormularyType":"OHP","DrugName":"HEADACHE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70030013538"},{"Id":414188,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"70030013608"},{"Id":414189,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"70030013613"},{"Id":414190,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70030013725"},{"Id":414191,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"70030013881"},{"Id":414192,"FormularyType":"OHP","DrugName":"SUPHEDRINE TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"70030013907"},{"Id":414193,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"70030013917"},{"Id":414194,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"70030013971"},{"Id":414195,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013996"},{"Id":414196,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70030013997"},{"Id":414197,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"70030014513"},{"Id":414198,"FormularyType":"OHP","DrugName":"MIGRAINE TAB FORMULA","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70030014581"},{"Id":414199,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70030014662"},{"Id":414200,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70030014667"},{"Id":414201,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70030014676"},{"Id":414202,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70030014733"},{"Id":414203,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70030014734"},{"Id":414204,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"70030014763"},{"Id":414205,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70030014828"},{"Id":414206,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70030014845"},{"Id":414207,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70030014846"},{"Id":414208,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"70030014891"},{"Id":414209,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70030014914"},{"Id":414210,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70030014915"},{"Id":414211,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70030014916"},{"Id":414212,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"70030014968"},{"Id":414213,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"70030014998"},{"Id":414214,"FormularyType":"OHP","DrugName":"OPTION 2 TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"70030051139"},{"Id":414215,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70030064045"},{"Id":414216,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70069000501"},{"Id":414217,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70069000510"},{"Id":414218,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"70069001701"},{"Id":414219,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"70069005101"},{"Id":414220,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"70069007101"},{"Id":414221,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"70069007110"},{"Id":414222,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL HCL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"70069008101"},{"Id":414223,"FormularyType":"OHP","DrugName":"AZELASTINE DRO 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802006102020","GenericName":"AZELASTINE HCL OPHTH SOLN 0.05%","NDC":"70069009101"},{"Id":414224,"FormularyType":"OHP","DrugName":"TROPICAMIDE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350050002010","GenericName":"TROPICAMIDE OPHTH SOLN 1%","NDC":"70069012101"},{"Id":414225,"FormularyType":"OHP","DrugName":"TOBRAMYCIN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101070002005","GenericName":"TOBRAMYCIN OPHTH SOLN 0.3%","NDC":"70069013101"},{"Id":414226,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70069017101"},{"Id":414227,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70069017110"},{"Id":414228,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70069017201"},{"Id":414229,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70069017210"},{"Id":414230,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102015","GenericName":"PILOCARPINE HCL OPHTH SOLN 1%","NDC":"70069018101"},{"Id":414231,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102020","GenericName":"PILOCARPINE HCL OPHTH SOLN 2%","NDC":"70069019101"},{"Id":414232,"FormularyType":"OHP","DrugName":"PILOCARPINE SOL 4% OP","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"MIOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86501030102030","GenericName":"PILOCARPINE HCL OPHTH SOLN 4%","NDC":"70069020101"},{"Id":414233,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"70069023101"},{"Id":414234,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"70069023201"},{"Id":414235,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"70069023301"},{"Id":414236,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70069027101"},{"Id":414237,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70069027105"},{"Id":414238,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70069027125"},{"Id":414239,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70069027201"},{"Id":414240,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 2.5MG/ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70069027205"},{"Id":414241,"FormularyType":"OHP","DrugName":"POLYMYXIN B/ SOL TRIMETHP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86109902602020","GenericName":"POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1%","NDC":"70069031101"},{"Id":414242,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"70069040101"},{"Id":414243,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"70069040201"},{"Id":414244,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"70069040301"},{"Id":414245,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"70069041101"},{"Id":414246,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"70069042101"},{"Id":414247,"FormularyType":"OHP","DrugName":"LATANOPROST SOL 0.005%","DosageForm":"SOLN - Solution","Strength":"0.005","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330050002020","GenericName":"LATANOPROST OPHTH SOLN 0.005%","NDC":"70069042103"},{"Id":414248,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"70069047101"},{"Id":414249,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"70069047110"},{"Id":414250,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"70069049101"},{"Id":414251,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"70069050101"},{"Id":414252,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"70069056601"},{"Id":414253,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"70069056701"},{"Id":414254,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"70069056801"},{"Id":414255,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70069058101"},{"Id":414256,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70069058201"},{"Id":414257,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70069058301"},{"Id":414258,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"70069058601"},{"Id":414259,"FormularyType":"OHP","DrugName":"TRAVOPROST DRO 0.004%","DosageForm":"SOLN - Solution","Strength":"0.004","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330070002025","GenericName":"TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","NDC":"70069058701"},{"Id":414260,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"70069068601"},{"Id":414261,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"70069068701"},{"Id":414262,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"70069070101"},{"Id":414263,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"70069070201"},{"Id":414264,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"70069070301"},{"Id":414265,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"70069070601"},{"Id":414266,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"70069070701"},{"Id":414267,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"70069070801"},{"Id":414268,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70069071601"},{"Id":414269,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"70069081001"},{"Id":414270,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70069081410"},{"Id":414271,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70069081430"},{"Id":414272,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70069081490"},{"Id":414273,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70069081510"},{"Id":414274,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70069081530"},{"Id":414275,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70069081590"},{"Id":414276,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102009","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/5ML (BASE EQUIVALENT)","NDC":"70069081701"},{"Id":414277,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102009","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/5ML (BASE EQUIVALENT)","NDC":"70069081710"},{"Id":414278,"FormularyType":"OHP","DrugName":"HYDROXYUREA CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700030000105","GenericName":"HYDROXYUREA CAP 500 MG","NDC":"70069082001"},{"Id":414279,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"70069082408"},{"Id":414280,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100310","GenericName":"ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","NDC":"70069083701"},{"Id":414281,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100320","GenericName":"ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","NDC":"70069083801"},{"Id":414282,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100330","GenericName":"ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","NDC":"70069083901"},{"Id":414283,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100340","GenericName":"ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","NDC":"70069084001"},{"Id":414284,"FormularyType":"OHP","DrugName":"RILPIVIRINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109080100320","GenericName":"RILPIVIRINE HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"70069084830"},{"Id":414285,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000143"},{"Id":414286,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000160"},{"Id":414287,"FormularyType":"OHP","DrugName":"REHYDRALYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000162"},{"Id":414288,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000240"},{"Id":414289,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FREEZE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000245"},{"Id":414290,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FREEZE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000246"},{"Id":414291,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000336"},{"Id":414292,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074000365"},{"Id":414293,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000373"},{"Id":414294,"FormularyType":"OHP","DrugName":"POLYCOSE LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100025000900","GenericName":"GLUCOSE POLYMERS LIQD","NDC":"70074000431"},{"Id":414295,"FormularyType":"OHP","DrugName":"FORTA DRINK POW ORANGE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000614"},{"Id":414296,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000617"},{"Id":414297,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW DTH CHOC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000618"},{"Id":414298,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW EGGNOG","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000619"},{"Id":414299,"FormularyType":"OHP","DrugName":"FORTA DRINK POW PUNCH","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000621"},{"Id":414300,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000699"},{"Id":414301,"FormularyType":"OHP","DrugName":"OSMOLITE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000709"},{"Id":414302,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HN VANIL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000721"},{"Id":414303,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000729"},{"Id":414304,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000735"},{"Id":414305,"FormularyType":"OHP","DrugName":"OSMOLITE HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000736"},{"Id":414306,"FormularyType":"OHP","DrugName":"OSMOLITE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000738"},{"Id":414307,"FormularyType":"OHP","DrugName":"POLYCOSE POW UNFLAVOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100025002910","GenericName":"GLUCOSE POLYMERS POWDER 94%","NDC":"70074000746"},{"Id":414308,"FormularyType":"OHP","DrugName":"ENSURE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000750"},{"Id":414309,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000756"},{"Id":414310,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074000759"},{"Id":414311,"FormularyType":"OHP","DrugName":"PROMOD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074000775"},{"Id":414312,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FREEZE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074002453"},{"Id":414313,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074011114"},{"Id":414314,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074011133"},{"Id":414315,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040143"},{"Id":414316,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074040160"},{"Id":414317,"FormularyType":"OHP","DrugName":"REHYDRALYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074040162"},{"Id":414318,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040373"},{"Id":414319,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW STRAWBER","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074040604"},{"Id":414320,"FormularyType":"OHP","DrugName":"FORTA DRINK POW ORANGE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074040614"},{"Id":414321,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074040617"},{"Id":414322,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW DTH CHOC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074040618"},{"Id":414323,"FormularyType":"OHP","DrugName":"FORTA SHAKE POW EGGNOG","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074040619"},{"Id":414324,"FormularyType":"OHP","DrugName":"FORTA DRINK POW FRT PUNC","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074040621"},{"Id":414325,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040699"},{"Id":414326,"FormularyType":"OHP","DrugName":"ENSURE NUTRI LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040701"},{"Id":414327,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040702"},{"Id":414328,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040705"},{"Id":414329,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040707"},{"Id":414330,"FormularyType":"OHP","DrugName":"ENSURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040711"},{"Id":414331,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040718"},{"Id":414332,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HN VANIL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040721"},{"Id":414333,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040729"},{"Id":414334,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040735"},{"Id":414335,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040756"},{"Id":414336,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074040759"},{"Id":414337,"FormularyType":"OHP","DrugName":"SUPLENA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050164"},{"Id":414338,"FormularyType":"OHP","DrugName":"SUPLENA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050165"},{"Id":414339,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050180"},{"Id":414340,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050181"},{"Id":414341,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050240"},{"Id":414342,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050241"},{"Id":414343,"FormularyType":"OHP","DrugName":"PROVIMIN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074050260"},{"Id":414344,"FormularyType":"OHP","DrugName":"PROVIMIN POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074050261"},{"Id":414345,"FormularyType":"OHP","DrugName":"ENSURE LIQ ACTIVE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050459"},{"Id":414346,"FormularyType":"OHP","DrugName":"ENSURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050463"},{"Id":414347,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050469"},{"Id":414348,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050514"},{"Id":414349,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050628"},{"Id":414350,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050629"},{"Id":414351,"FormularyType":"OHP","DrugName":"NEPRO LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050633"},{"Id":414352,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050646"},{"Id":414353,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050650"},{"Id":414354,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050651"},{"Id":414355,"FormularyType":"OHP","DrugName":"PROMOTE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050774"},{"Id":414356,"FormularyType":"OHP","DrugName":"PROMOTE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050775"},{"Id":414357,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050904"},{"Id":414358,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050905"},{"Id":414359,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074050907"},{"Id":414360,"FormularyType":"OHP","DrugName":"KETONEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051113"},{"Id":414361,"FormularyType":"OHP","DrugName":"KETONEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051115"},{"Id":414362,"FormularyType":"OHP","DrugName":"HOMINEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051117"},{"Id":414363,"FormularyType":"OHP","DrugName":"HOMINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051119"},{"Id":414364,"FormularyType":"OHP","DrugName":"PHENEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051121"},{"Id":414365,"FormularyType":"OHP","DrugName":"PHENEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051123"},{"Id":414366,"FormularyType":"OHP","DrugName":"TYREX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051127"},{"Id":414367,"FormularyType":"OHP","DrugName":"TYREX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051129"},{"Id":414368,"FormularyType":"OHP","DrugName":"PROPIMEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051133"},{"Id":414369,"FormularyType":"OHP","DrugName":"PROPIMEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051135"},{"Id":414370,"FormularyType":"OHP","DrugName":"I-VALEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051137"},{"Id":414371,"FormularyType":"OHP","DrugName":"I-VALEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051139"},{"Id":414372,"FormularyType":"OHP","DrugName":"GLUTAREX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051141"},{"Id":414373,"FormularyType":"OHP","DrugName":"GLUTAREX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051143"},{"Id":414374,"FormularyType":"OHP","DrugName":"CYCLINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051146"},{"Id":414375,"FormularyType":"OHP","DrugName":"CYCLINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051147"},{"Id":414376,"FormularyType":"OHP","DrugName":"PRO-PHREE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074051149"},{"Id":414377,"FormularyType":"OHP","DrugName":"ADVERA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051305"},{"Id":414378,"FormularyType":"OHP","DrugName":"PROMOTE LIQ R-T-HANG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051617"},{"Id":414379,"FormularyType":"OHP","DrugName":"EQUALYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074051666"},{"Id":414380,"FormularyType":"OHP","DrugName":"ENSURE LIQ COFFEE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051739"},{"Id":414381,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ RTU COFF","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051740"},{"Id":414382,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ RTU COFF","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051741"},{"Id":414383,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ RTU EGNG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051742"},{"Id":414384,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ RTU EGNG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051743"},{"Id":414385,"FormularyType":"OHP","DrugName":"ENSURE LIQ RTU EGNG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051744"},{"Id":414386,"FormularyType":"OHP","DrugName":"ENSURE LIQ RTU EGNG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051745"},{"Id":414387,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BUBL GUM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074051752"},{"Id":414388,"FormularyType":"OHP","DrugName":"ENSURE LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051785"},{"Id":414389,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051787"},{"Id":414390,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051808"},{"Id":414391,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051809"},{"Id":414392,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051810"},{"Id":414393,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051811"},{"Id":414394,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051812"},{"Id":414395,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051813"},{"Id":414396,"FormularyType":"OHP","DrugName":"PROMOTE W/FB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051872"},{"Id":414397,"FormularyType":"OHP","DrugName":"PROMOTE W/ LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051873"},{"Id":414398,"FormularyType":"OHP","DrugName":"ENSURE LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051893"},{"Id":414399,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074051949"},{"Id":414400,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052098"},{"Id":414401,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052099"},{"Id":414402,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052100"},{"Id":414403,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052101"},{"Id":414404,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052102"},{"Id":414405,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ WLD BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052104"},{"Id":414406,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ WLD BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052105"},{"Id":414407,"FormularyType":"OHP","DrugName":"ADVERA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052452"},{"Id":414408,"FormularyType":"OHP","DrugName":"ADVERA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052453"},{"Id":414409,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052601"},{"Id":414410,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ R-T-HANG","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052603"},{"Id":414411,"FormularyType":"OHP","DrugName":"ENSURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074052637"},{"Id":414412,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053118"},{"Id":414413,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053119"},{"Id":414414,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053121"},{"Id":414415,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053123"},{"Id":414416,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053205"},{"Id":414417,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053207"},{"Id":414418,"FormularyType":"OHP","DrugName":"ENSURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053432"},{"Id":414419,"FormularyType":"OHP","DrugName":"ENLIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053463"},{"Id":414420,"FormularyType":"OHP","DrugName":"ELECARE POW DHA/ARA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074053510"},{"Id":414421,"FormularyType":"OHP","DrugName":"ELECARE DHA/ POW ARA INFA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074053511"},{"Id":414422,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053534"},{"Id":414423,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053535"},{"Id":414424,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053537"},{"Id":414425,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053592"},{"Id":414426,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053594"},{"Id":414427,"FormularyType":"OHP","DrugName":"ENSURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053623"},{"Id":414428,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053626"},{"Id":414429,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ BT.PECAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053629"},{"Id":414430,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ MX BERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053632"},{"Id":414431,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053634"},{"Id":414432,"FormularyType":"OHP","DrugName":"SUPLENA/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053638"},{"Id":414433,"FormularyType":"OHP","DrugName":"ENSURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053806"},{"Id":414434,"FormularyType":"OHP","DrugName":"ENSURE LIQ DK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053807"},{"Id":414435,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ DRK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053809"},{"Id":414436,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ DRK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053810"},{"Id":414437,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ BERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053820"},{"Id":414438,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ BRY CRM","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074053824"},{"Id":414439,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL STRAWBRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074053984"},{"Id":414440,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054064"},{"Id":414441,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054065"},{"Id":414442,"FormularyType":"OHP","DrugName":"NEPRO LIQ BT.PECAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054104"},{"Id":414443,"FormularyType":"OHP","DrugName":"NEPRO LIQ BT.PECAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054105"},{"Id":414444,"FormularyType":"OHP","DrugName":"NEPRO LIQ CHERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054106"},{"Id":414445,"FormularyType":"OHP","DrugName":"NEPRO LIQ CHERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054107"},{"Id":414446,"FormularyType":"OHP","DrugName":"GLUCERNA OS LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054322"},{"Id":414447,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054326"},{"Id":414448,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054327"},{"Id":414449,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054328"},{"Id":414450,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054329"},{"Id":414451,"FormularyType":"OHP","DrugName":"OXEPA LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054386"},{"Id":414452,"FormularyType":"OHP","DrugName":"OXEPA LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054387"},{"Id":414453,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054408"},{"Id":414454,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054544"},{"Id":414455,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054545"},{"Id":414456,"FormularyType":"OHP","DrugName":"GLUCERNA OS LIQ CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054554"},{"Id":414457,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054556"},{"Id":414458,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054569"},{"Id":414459,"FormularyType":"OHP","DrugName":"OPTIMENTAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054638"},{"Id":414460,"FormularyType":"OHP","DrugName":"OPTIMENTAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054639"},{"Id":414461,"FormularyType":"OHP","DrugName":"OPTIMENTAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054640"},{"Id":414462,"FormularyType":"OHP","DrugName":"ELECARE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054665"},{"Id":414463,"FormularyType":"OHP","DrugName":"ELECARE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054666"},{"Id":414464,"FormularyType":"OHP","DrugName":"ENSURE HIGH LIQ CAL CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054825"},{"Id":414465,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054939"},{"Id":414466,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054940"},{"Id":414467,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW STRAWBER","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054941"},{"Id":414468,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW STRAWBER","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054942"},{"Id":414469,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW CHOCOLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054943"},{"Id":414470,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054944"},{"Id":414471,"FormularyType":"OHP","DrugName":"HEALTH SOURC POW UNFLAVOR","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074054945"},{"Id":414472,"FormularyType":"OHP","DrugName":"EQUATE PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054953"},{"Id":414473,"FormularyType":"OHP","DrugName":"EQUATE PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054955"},{"Id":414474,"FormularyType":"OHP","DrugName":"EQUATE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054956"},{"Id":414475,"FormularyType":"OHP","DrugName":"EQUATE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054958"},{"Id":414476,"FormularyType":"OHP","DrugName":"EQUATE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054959"},{"Id":414477,"FormularyType":"OHP","DrugName":"EQUATE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054961"},{"Id":414478,"FormularyType":"OHP","DrugName":"EQUATE LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054962"},{"Id":414479,"FormularyType":"OHP","DrugName":"EQUATE LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054964"},{"Id":414480,"FormularyType":"OHP","DrugName":"EQUATE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054965"},{"Id":414481,"FormularyType":"OHP","DrugName":"EQUATE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054967"},{"Id":414482,"FormularyType":"OHP","DrugName":"EQUATE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054968"},{"Id":414483,"FormularyType":"OHP","DrugName":"EQUATE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074054970"},{"Id":414484,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074054981"},{"Id":414485,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074054982"},{"Id":414486,"FormularyType":"OHP","DrugName":"ELECARE POW DHA/ARA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074055251"},{"Id":414487,"FormularyType":"OHP","DrugName":"ELECARE JR POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074055253"},{"Id":414488,"FormularyType":"OHP","DrugName":"ELECARE JR POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074055254"},{"Id":414489,"FormularyType":"OHP","DrugName":"ENSURE/FIBER LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055315"},{"Id":414490,"FormularyType":"OHP","DrugName":"ELECARE POW DHA/ARA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074055351"},{"Id":414491,"FormularyType":"OHP","DrugName":"RE/NEPH LP/H LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055431"},{"Id":414492,"FormularyType":"OHP","DrugName":"RE/NEPH LP/H LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055433"},{"Id":414493,"FormularyType":"OHP","DrugName":"RE/NEPH LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055434"},{"Id":414494,"FormularyType":"OHP","DrugName":"RE/NEPH LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055435"},{"Id":414495,"FormularyType":"OHP","DrugName":"RE/NEPH LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055436"},{"Id":414496,"FormularyType":"OHP","DrugName":"PHENEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074055756"},{"Id":414497,"FormularyType":"OHP","DrugName":"NUTRIFOCUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055859"},{"Id":414498,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074055905"},{"Id":414499,"FormularyType":"OHP","DrugName":"ENSURE LIQ COFF LAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056016"},{"Id":414500,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056052"},{"Id":414501,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056277"},{"Id":414502,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056278"},{"Id":414503,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056279"},{"Id":414504,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056280"},{"Id":414505,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056282"},{"Id":414506,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056284"},{"Id":414507,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056369"},{"Id":414508,"FormularyType":"OHP","DrugName":"VITAL JR LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056383"},{"Id":414509,"FormularyType":"OHP","DrugName":"VITAL JR LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056390"},{"Id":414510,"FormularyType":"OHP","DrugName":"VITAL JR LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056392"},{"Id":414511,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056417"},{"Id":414512,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056420"},{"Id":414513,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056423"},{"Id":414514,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074056436"},{"Id":414515,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074056437"},{"Id":414516,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074056439"},{"Id":414517,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074056440"},{"Id":414518,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074056442"},{"Id":414519,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074056443"},{"Id":414520,"FormularyType":"OHP","DrugName":"ENSURE LIQ IMMUNE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056459"},{"Id":414521,"FormularyType":"OHP","DrugName":"ENSURE LIQ IMMUNE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056462"},{"Id":414522,"FormularyType":"OHP","DrugName":"ENSURE LIQ IMMUNE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056468"},{"Id":414523,"FormularyType":"OHP","DrugName":"ENSURE BONE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056471"},{"Id":414524,"FormularyType":"OHP","DrugName":"ENSURE BONE LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056474"},{"Id":414525,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056477"},{"Id":414526,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056480"},{"Id":414527,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ STRWB/CR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056483"},{"Id":414528,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056486"},{"Id":414529,"FormularyType":"OHP","DrugName":"ENSURE CLIN LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056489"},{"Id":414530,"FormularyType":"OHP","DrugName":"ENSURE CLIN LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056492"},{"Id":414531,"FormularyType":"OHP","DrugName":"ENSURE CLIN LIQ STRW/CRM","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056495"},{"Id":414532,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ BBRY/POM","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056500"},{"Id":414533,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ BBRY/POM","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056502"},{"Id":414534,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056524"},{"Id":414535,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056543"},{"Id":414536,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056545"},{"Id":414537,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056559"},{"Id":414538,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056561"},{"Id":414539,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056562"},{"Id":414540,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056563"},{"Id":414541,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056564"},{"Id":414542,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056565"},{"Id":414543,"FormularyType":"OHP","DrugName":"ELECARE JR POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074056585"},{"Id":414544,"FormularyType":"OHP","DrugName":"ELECARE JR POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074056586"},{"Id":414545,"FormularyType":"OHP","DrugName":"ELECARE JR POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074056588"},{"Id":414546,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ PEACH","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056604"},{"Id":414547,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ PEACH","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056606"},{"Id":414548,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056640"},{"Id":414549,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056641"},{"Id":414550,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056642"},{"Id":414551,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074056643"},{"Id":414552,"FormularyType":"OHP","DrugName":"OXEPA LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057044"},{"Id":414553,"FormularyType":"OHP","DrugName":"OPTIMENTAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057046"},{"Id":414554,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057048"},{"Id":414555,"FormularyType":"OHP","DrugName":"ENSURE NUTRI LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057231"},{"Id":414556,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057234"},{"Id":414557,"FormularyType":"OHP","DrugName":"ENSURE NUTRI LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057243"},{"Id":414558,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057263"},{"Id":414559,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057266"},{"Id":414560,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057269"},{"Id":414561,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057333"},{"Id":414562,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057334"},{"Id":414563,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL SINGLES","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074057426"},{"Id":414564,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057464"},{"Id":414565,"FormularyType":"OHP","DrugName":"OSMOLITE 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057470"},{"Id":414566,"FormularyType":"OHP","DrugName":"PROMOTE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057632"},{"Id":414567,"FormularyType":"OHP","DrugName":"PROMOTE W/FB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057634"},{"Id":414568,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057636"},{"Id":414569,"FormularyType":"OHP","DrugName":"GLUCERNA SEL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057702"},{"Id":414570,"FormularyType":"OHP","DrugName":"ENSURE NUTRI LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057753"},{"Id":414571,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057755"},{"Id":414572,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057802"},{"Id":414573,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057803"},{"Id":414574,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057805"},{"Id":414575,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057806"},{"Id":414576,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057808"},{"Id":414577,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057809"},{"Id":414578,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057811"},{"Id":414579,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057812"},{"Id":414580,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074057842"},{"Id":414581,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058013"},{"Id":414582,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058014"},{"Id":414583,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058016"},{"Id":414584,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058049"},{"Id":414585,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058050"},{"Id":414586,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058053"},{"Id":414587,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058056"},{"Id":414588,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058058"},{"Id":414589,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058059"},{"Id":414590,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058062"},{"Id":414591,"FormularyType":"OHP","DrugName":"HEALTHY MOM LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058235"},{"Id":414592,"FormularyType":"OHP","DrugName":"HEALTHY MOM LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058238"},{"Id":414593,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058252"},{"Id":414594,"FormularyType":"OHP","DrugName":"HI-CAL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058253"},{"Id":414595,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058263"},{"Id":414596,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058293"},{"Id":414597,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058294"},{"Id":414598,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058295"},{"Id":414599,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058296"},{"Id":414600,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058297"},{"Id":414601,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058298"},{"Id":414602,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058299"},{"Id":414603,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058300"},{"Id":414604,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058301"},{"Id":414605,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058302"},{"Id":414606,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058303"},{"Id":414607,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074058304"},{"Id":414608,"FormularyType":"OHP","DrugName":"ELECARE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074059405"},{"Id":414609,"FormularyType":"OHP","DrugName":"ELECARE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074059406"},{"Id":414610,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ NUTRIPAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059549"},{"Id":414611,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ NUTRIPAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059555"},{"Id":414612,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ NUTRIPAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059558"},{"Id":414613,"FormularyType":"OHP","DrugName":"PROMOD LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059721"},{"Id":414614,"FormularyType":"OHP","DrugName":"VITAL JR LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059761"},{"Id":414615,"FormularyType":"OHP","DrugName":"VITAL JR LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059763"},{"Id":414616,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059857"},{"Id":414617,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059858"},{"Id":414618,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059860"},{"Id":414619,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074059861"},{"Id":414620,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074059892"},{"Id":414621,"FormularyType":"OHP","DrugName":"OSMOLITE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074060738"},{"Id":414622,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074060739"},{"Id":414623,"FormularyType":"OHP","DrugName":"ENSURE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074060750"},{"Id":414624,"FormularyType":"OHP","DrugName":"PROMOD POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074060775"},{"Id":414625,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062010"},{"Id":414626,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062011"},{"Id":414627,"FormularyType":"OHP","DrugName":"ENSURE MUSCL LIQ STRW/CRM","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062013"},{"Id":414628,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062014"},{"Id":414629,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062015"},{"Id":414630,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062020"},{"Id":414631,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062021"},{"Id":414632,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062023"},{"Id":414633,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062051"},{"Id":414634,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062052"},{"Id":414635,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062060"},{"Id":414636,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062061"},{"Id":414637,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062063"},{"Id":414638,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062064"},{"Id":414639,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062067"},{"Id":414640,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062068"},{"Id":414641,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062069"},{"Id":414642,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062070"},{"Id":414643,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062071"},{"Id":414644,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062072"},{"Id":414645,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062082"},{"Id":414646,"FormularyType":"OHP","DrugName":"SUPLENA/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062088"},{"Id":414647,"FormularyType":"OHP","DrugName":"SUPLENA/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062089"},{"Id":414648,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ BT.PECAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062091"},{"Id":414649,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ MX BERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062093"},{"Id":414650,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062095"},{"Id":414651,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ TROP FRT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062125"},{"Id":414652,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ TROP FRT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062126"},{"Id":414653,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ TROP FRT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062127"},{"Id":414654,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ WLD BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062130"},{"Id":414655,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ WLD BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062131"},{"Id":414656,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ WLD BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062132"},{"Id":414657,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062309"},{"Id":414658,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062310"},{"Id":414659,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062311"},{"Id":414660,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ SIDEKICK","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062312"},{"Id":414661,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062342"},{"Id":414662,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062344"},{"Id":414663,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062348"},{"Id":414664,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062350"},{"Id":414665,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062352"},{"Id":414666,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062354"},{"Id":414667,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062356"},{"Id":414668,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062364"},{"Id":414669,"FormularyType":"OHP","DrugName":"OPTIMENTAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062370"},{"Id":414670,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062374"},{"Id":414671,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062376"},{"Id":414672,"FormularyType":"OHP","DrugName":"OXEPA LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062382"},{"Id":414673,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062384"},{"Id":414674,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062386"},{"Id":414675,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062388"},{"Id":414676,"FormularyType":"OHP","DrugName":"PROMOTE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062390"},{"Id":414677,"FormularyType":"OHP","DrugName":"PROMOTE W/ LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062392"},{"Id":414678,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062394"},{"Id":414679,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062396"},{"Id":414680,"FormularyType":"OHP","DrugName":"SIMILAC PREN PAK EARLY SH","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006312","GenericName":"*PRENATAL W/FE FUM-FA TAB 27-0.8 MG & DHA CAP 200 MG PACK *","NDC":"70074062427"},{"Id":414681,"FormularyType":"OHP","DrugName":"SIMILAC PREN PAK EARLY SH","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78516020006312","GenericName":"*PRENATAL W/FE FUM-FA TAB 27-0.8 MG & DHA CAP 200 MG PACK *","NDC":"70074062428"},{"Id":414682,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX FRUT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062479"},{"Id":414683,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX FRUT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062480"},{"Id":414684,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX FRUT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062481"},{"Id":414685,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062483"},{"Id":414686,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062485"},{"Id":414687,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062487"},{"Id":414688,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062495"},{"Id":414689,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062585"},{"Id":414690,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062667"},{"Id":414691,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062668"},{"Id":414692,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ STEADY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062669"},{"Id":414693,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ STEADY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062670"},{"Id":414694,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062671"},{"Id":414695,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062672"},{"Id":414696,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062673"},{"Id":414697,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062674"},{"Id":414698,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062675"},{"Id":414699,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062676"},{"Id":414700,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062677"},{"Id":414701,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062678"},{"Id":414702,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062679"},{"Id":414703,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062680"},{"Id":414704,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062681"},{"Id":414705,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062682"},{"Id":414706,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062683"},{"Id":414707,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062684"},{"Id":414708,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062685"},{"Id":414709,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062686"},{"Id":414710,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062687"},{"Id":414711,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062688"},{"Id":414712,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062689"},{"Id":414713,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062690"},{"Id":414714,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062691"},{"Id":414715,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062692"},{"Id":414716,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062693"},{"Id":414717,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062694"},{"Id":414718,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062695"},{"Id":414719,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062696"},{"Id":414720,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062697"},{"Id":414721,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062698"},{"Id":414722,"FormularyType":"OHP","DrugName":"OSMOLITE 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062699"},{"Id":414723,"FormularyType":"OHP","DrugName":"OSMOLITE 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062700"},{"Id":414724,"FormularyType":"OHP","DrugName":"PROMOTE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062701"},{"Id":414725,"FormularyType":"OHP","DrugName":"PROMOTE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062702"},{"Id":414726,"FormularyType":"OHP","DrugName":"PROMOTE/ LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062704"},{"Id":414727,"FormularyType":"OHP","DrugName":"PROMOTE/ LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062705"},{"Id":414728,"FormularyType":"OHP","DrugName":"PROMOTE/ LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062706"},{"Id":414729,"FormularyType":"OHP","DrugName":"PROMOTE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062707"},{"Id":414730,"FormularyType":"OHP","DrugName":"PROMOTE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062708"},{"Id":414731,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062709"},{"Id":414732,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062710"},{"Id":414733,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062711"},{"Id":414734,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062712"},{"Id":414735,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062713"},{"Id":414736,"FormularyType":"OHP","DrugName":"VITAL 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062714"},{"Id":414737,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062715"},{"Id":414738,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062716"},{"Id":414739,"FormularyType":"OHP","DrugName":"OXEPA LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062717"},{"Id":414740,"FormularyType":"OHP","DrugName":"OXEPA LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062718"},{"Id":414741,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062719"},{"Id":414742,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062720"},{"Id":414743,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062721"},{"Id":414744,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062722"},{"Id":414745,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062723"},{"Id":414746,"FormularyType":"OHP","DrugName":"PERATIVE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062724"},{"Id":414747,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062725"},{"Id":414748,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062726"},{"Id":414749,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062759"},{"Id":414750,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062762"},{"Id":414751,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062802"},{"Id":414752,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062803"},{"Id":414753,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062805"},{"Id":414754,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062806"},{"Id":414755,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062882"},{"Id":414756,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062884"},{"Id":414757,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOALT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062885"},{"Id":414758,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062887"},{"Id":414759,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062932"},{"Id":414760,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074062999"},{"Id":414761,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063000"},{"Id":414762,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063001"},{"Id":414763,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063002"},{"Id":414764,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063055"},{"Id":414765,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL CHRY PUN","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074063057"},{"Id":414766,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL CHRY PUN","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074063058"},{"Id":414767,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BLU RASP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074063059"},{"Id":414768,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BLU RASP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074063060"},{"Id":414769,"FormularyType":"OHP","DrugName":"ENSURE HIGH POW PROTEIN","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074063074"},{"Id":414770,"FormularyType":"OHP","DrugName":"VITAL HP LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063081"},{"Id":414771,"FormularyType":"OHP","DrugName":"VITAL HP LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063082"},{"Id":414772,"FormularyType":"OHP","DrugName":"ENSURE HIGH POW PROTEIN","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074063084"},{"Id":414773,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063177"},{"Id":414774,"FormularyType":"OHP","DrugName":"PEDIASURE POW SHAKE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074063343"},{"Id":414775,"FormularyType":"OHP","DrugName":"PEDIASURE POW SHAKE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074063344"},{"Id":414776,"FormularyType":"OHP","DrugName":"ENSURE LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074063389"},{"Id":414777,"FormularyType":"OHP","DrugName":"PEDIASURE POW SIDEKICK","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074064113"},{"Id":414778,"FormularyType":"OHP","DrugName":"PEDIASURE POW SIDEKICK","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074064114"},{"Id":414779,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ HP","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064115"},{"Id":414780,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ MILK CHO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064116"},{"Id":414781,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ HP","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064117"},{"Id":414782,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ HP","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064118"},{"Id":414783,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ LIGHT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064121"},{"Id":414784,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ LIGHT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064122"},{"Id":414785,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ LIGHT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064123"},{"Id":414786,"FormularyType":"OHP","DrugName":"ENSURE ACTIV LIQ LIGHT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064124"},{"Id":414787,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064134"},{"Id":414788,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064135"},{"Id":414789,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064136"},{"Id":414790,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064137"},{"Id":414791,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064273"},{"Id":414792,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064281"},{"Id":414793,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064282"},{"Id":414794,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064283"},{"Id":414795,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064284"},{"Id":414796,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064286"},{"Id":414797,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064290"},{"Id":414798,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064292"},{"Id":414799,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064294"},{"Id":414800,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064297"},{"Id":414801,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074064301"},{"Id":414802,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074064302"},{"Id":414803,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074064307"},{"Id":414804,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074064308"},{"Id":414805,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064349"},{"Id":414806,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064353"},{"Id":414807,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064356"},{"Id":414808,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064357"},{"Id":414809,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064359"},{"Id":414810,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064361"},{"Id":414811,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064362"},{"Id":414812,"FormularyType":"OHP","DrugName":"ENSURE COMPA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064363"},{"Id":414813,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064588"},{"Id":414814,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064589"},{"Id":414815,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064590"},{"Id":414816,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064624"},{"Id":414817,"FormularyType":"OHP","DrugName":"JEVITY 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064625"},{"Id":414818,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL/FIBE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064626"},{"Id":414819,"FormularyType":"OHP","DrugName":"JEVITY 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064628"},{"Id":414820,"FormularyType":"OHP","DrugName":"PROMOTE 1.0 LIQ W/ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064629"},{"Id":414821,"FormularyType":"OHP","DrugName":"PROMOTE 1.0 LIQ W/ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064631"},{"Id":414822,"FormularyType":"OHP","DrugName":"OSMOLITE LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064632"},{"Id":414823,"FormularyType":"OHP","DrugName":"OSMOLITE LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064633"},{"Id":414824,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064634"},{"Id":414825,"FormularyType":"OHP","DrugName":"OSMOLITE 1.2 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064635"},{"Id":414826,"FormularyType":"OHP","DrugName":"ENSURE LIQ ENLIVE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064721"},{"Id":414827,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064758"},{"Id":414828,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064759"},{"Id":414829,"FormularyType":"OHP","DrugName":"ENSURE ENLIV LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064760"},{"Id":414830,"FormularyType":"OHP","DrugName":"SUPLENA 1.8 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064793"},{"Id":414831,"FormularyType":"OHP","DrugName":"SUPLENA 1.8 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064794"},{"Id":414832,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ MX BERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064795"},{"Id":414833,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ STEADY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064797"},{"Id":414834,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064799"},{"Id":414835,"FormularyType":"OHP","DrugName":"NEPRO/CARB LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064803"},{"Id":414836,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ 2.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064804"},{"Id":414837,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ 2.0 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064807"},{"Id":414838,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ 2.0 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064809"},{"Id":414839,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ 1.5 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064810"},{"Id":414840,"FormularyType":"OHP","DrugName":"PULMOCARE LIQ 1.5 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064811"},{"Id":414841,"FormularyType":"OHP","DrugName":"OXEPA 1.5 LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064813"},{"Id":414842,"FormularyType":"OHP","DrugName":"PERATIVE LIQ 1.3 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064815"},{"Id":414843,"FormularyType":"OHP","DrugName":"PERATIVE LIQ 1.3 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064816"},{"Id":414844,"FormularyType":"OHP","DrugName":"VITAL HP LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064817"},{"Id":414845,"FormularyType":"OHP","DrugName":"VITAL HP LIQ 1.0 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064820"},{"Id":414846,"FormularyType":"OHP","DrugName":"VITAL 1.5 CA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064824"},{"Id":414847,"FormularyType":"OHP","DrugName":"VITAL 1.5 CA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064825"},{"Id":414848,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064826"},{"Id":414849,"FormularyType":"OHP","DrugName":"VITAL AF 1.2 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064828"},{"Id":414850,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064829"},{"Id":414851,"FormularyType":"OHP","DrugName":"VITAL 1.0 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064832"},{"Id":414852,"FormularyType":"OHP","DrugName":"PROMOTE 1.0 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064833"},{"Id":414853,"FormularyType":"OHP","DrugName":"PROMOTE 1.0 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064834"},{"Id":414854,"FormularyType":"OHP","DrugName":"OSMOLITE 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064835"},{"Id":414855,"FormularyType":"OHP","DrugName":"OSMOLITE 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064837"},{"Id":414856,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064894"},{"Id":414857,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064895"},{"Id":414858,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064896"},{"Id":414859,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064898"},{"Id":414860,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064899"},{"Id":414861,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ MIX BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064900"},{"Id":414862,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064901"},{"Id":414863,"FormularyType":"OHP","DrugName":"ENSURE CLEAR LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064903"},{"Id":414864,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064904"},{"Id":414865,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064905"},{"Id":414866,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064906"},{"Id":414867,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ STRWBERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064907"},{"Id":414868,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064908"},{"Id":414869,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ BUT PECN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064909"},{"Id":414870,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064910"},{"Id":414871,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064911"},{"Id":414872,"FormularyType":"OHP","DrugName":"GLUCERNA 1.0 LIQ CARB VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064912"},{"Id":414873,"FormularyType":"OHP","DrugName":"GLUCERNA 1.0 LIQ CARB VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064913"},{"Id":414874,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064916"},{"Id":414875,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064918"},{"Id":414876,"FormularyType":"OHP","DrugName":"GLUCERNA 1.5 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064919"},{"Id":414877,"FormularyType":"OHP","DrugName":"GLUCERNA 1.5 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064920"},{"Id":414878,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064921"},{"Id":414879,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064922"},{"Id":414880,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064924"},{"Id":414881,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064925"},{"Id":414882,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ BUT PECA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064926"},{"Id":414883,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ BUT PECA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064927"},{"Id":414884,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064928"},{"Id":414885,"FormularyType":"OHP","DrugName":"GLUCERNA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064929"},{"Id":414886,"FormularyType":"OHP","DrugName":"ENSURE LIQ ORIGINAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064930"},{"Id":414887,"FormularyType":"OHP","DrugName":"ENSURE ORIG LIQ THERAPEU","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064931"},{"Id":414888,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064932"},{"Id":414889,"FormularyType":"OHP","DrugName":"ENSURE LIQ STRWBERR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064933"},{"Id":414890,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ B PECAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064934"},{"Id":414891,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ B PECAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064935"},{"Id":414892,"FormularyType":"OHP","DrugName":"ENSURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064936"},{"Id":414893,"FormularyType":"OHP","DrugName":"ENSURE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074064937"},{"Id":414894,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074065006"},{"Id":414895,"FormularyType":"OHP","DrugName":"PIVOT LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074065007"},{"Id":414896,"FormularyType":"OHP","DrugName":"ENSURE PRE LIQ SURGERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074065040"},{"Id":414897,"FormularyType":"OHP","DrugName":"ENSURE PRE LIQ SURGERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074065044"},{"Id":414898,"FormularyType":"OHP","DrugName":"ENSURE SURGE LIQ IMMUNO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074065046"},{"Id":414899,"FormularyType":"OHP","DrugName":"ENSURE SURGE LIQ IMMUNO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074065047"},{"Id":414900,"FormularyType":"OHP","DrugName":"VITAL PEPTID LIQ 1.5 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066236"},{"Id":414901,"FormularyType":"OHP","DrugName":"VITAL PEPTID LIQ 1.5 VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066237"},{"Id":414902,"FormularyType":"OHP","DrugName":"ELECARE JR POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066271"},{"Id":414903,"FormularyType":"OHP","DrugName":"ELECARE JR POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066273"},{"Id":414904,"FormularyType":"OHP","DrugName":"ELECARE JR POW BANANA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066275"},{"Id":414905,"FormularyType":"OHP","DrugName":"ELECARE JR POW BANANA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066276"},{"Id":414906,"FormularyType":"OHP","DrugName":"ENSURE SURGE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066436"},{"Id":414907,"FormularyType":"OHP","DrugName":"ENSURE PRE LIQ SURGERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066437"},{"Id":414908,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066535"},{"Id":414909,"FormularyType":"OHP","DrugName":"ENSURE HP LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066547"},{"Id":414910,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066639"},{"Id":414911,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066640"},{"Id":414912,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074066641"},{"Id":414913,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074066642"},{"Id":414914,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074066643"},{"Id":414915,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074066644"},{"Id":414916,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ HARVEST","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066670"},{"Id":414917,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ HARVEST","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066673"},{"Id":414918,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ CHOC CAR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066795"},{"Id":414919,"FormularyType":"OHP","DrugName":"ENSURE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066853"},{"Id":414920,"FormularyType":"OHP","DrugName":"ENSURE ORIGN POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066854"},{"Id":414921,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ CAFE MOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066891"},{"Id":414922,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ CAFE MOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066892"},{"Id":414923,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ CAFE MOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066893"},{"Id":414924,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066897"},{"Id":414925,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066898"},{"Id":414926,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ MLK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066899"},{"Id":414927,"FormularyType":"OHP","DrugName":"ENSURE ORIGN LIQ BAN NUT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066911"},{"Id":414928,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066912"},{"Id":414929,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066913"},{"Id":414930,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066916"},{"Id":414931,"FormularyType":"OHP","DrugName":"SIDEKICKS LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066917"},{"Id":414932,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ S'MORES","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066918"},{"Id":414933,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ S'MORES","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074066920"},{"Id":414934,"FormularyType":"OHP","DrugName":"ENSURE ORIGN POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066950"},{"Id":414935,"FormularyType":"OHP","DrugName":"PEDIASURE POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066954"},{"Id":414936,"FormularyType":"OHP","DrugName":"PEDIASURE POW CHOCOLAT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074066956"},{"Id":414937,"FormularyType":"OHP","DrugName":"PRO-PHREE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067031"},{"Id":414938,"FormularyType":"OHP","DrugName":"CYCLINEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067033"},{"Id":414939,"FormularyType":"OHP","DrugName":"CYCLINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067034"},{"Id":414940,"FormularyType":"OHP","DrugName":"CYCLINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067035"},{"Id":414941,"FormularyType":"OHP","DrugName":"GLUTAREX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067037"},{"Id":414942,"FormularyType":"OHP","DrugName":"GLUTAREX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067038"},{"Id":414943,"FormularyType":"OHP","DrugName":"GLUTAREX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067039"},{"Id":414944,"FormularyType":"OHP","DrugName":"HOMINEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067041"},{"Id":414945,"FormularyType":"OHP","DrugName":"HOMINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067042"},{"Id":414946,"FormularyType":"OHP","DrugName":"HOMINEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067043"},{"Id":414947,"FormularyType":"OHP","DrugName":"I-VALEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067045"},{"Id":414948,"FormularyType":"OHP","DrugName":"I-VALEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067046"},{"Id":414949,"FormularyType":"OHP","DrugName":"I-VALEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067047"},{"Id":414950,"FormularyType":"OHP","DrugName":"KETONEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067049"},{"Id":414951,"FormularyType":"OHP","DrugName":"KETONEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067050"},{"Id":414952,"FormularyType":"OHP","DrugName":"KETONEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067051"},{"Id":414953,"FormularyType":"OHP","DrugName":"PHENEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067053"},{"Id":414954,"FormularyType":"OHP","DrugName":"PHENEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067054"},{"Id":414955,"FormularyType":"OHP","DrugName":"PHENEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067055"},{"Id":414956,"FormularyType":"OHP","DrugName":"PHENEX-2 POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067056"},{"Id":414957,"FormularyType":"OHP","DrugName":"PHENEX-2 POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067057"},{"Id":414958,"FormularyType":"OHP","DrugName":"PROPIMEX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067059"},{"Id":414959,"FormularyType":"OHP","DrugName":"PROPIMEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067060"},{"Id":414960,"FormularyType":"OHP","DrugName":"PROPIMEX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067061"},{"Id":414961,"FormularyType":"OHP","DrugName":"TYREX-1 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067063"},{"Id":414962,"FormularyType":"OHP","DrugName":"TYREX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067064"},{"Id":414963,"FormularyType":"OHP","DrugName":"TYREX-2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074067065"},{"Id":414964,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067067"},{"Id":414965,"FormularyType":"OHP","DrugName":"GLUCERNA SHK LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067068"},{"Id":414966,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067073"},{"Id":414967,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067074"},{"Id":414968,"FormularyType":"OHP","DrugName":"ENSURE ORIGI LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067082"},{"Id":414969,"FormularyType":"OHP","DrugName":"ENSURE ORIGI LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067083"},{"Id":414970,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067086"},{"Id":414971,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067087"},{"Id":414972,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ FR VANIL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067166"},{"Id":414973,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ FR VANIL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067167"},{"Id":414974,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067185"},{"Id":414975,"FormularyType":"OHP","DrugName":"PEIDASURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067214"},{"Id":414976,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067215"},{"Id":414977,"FormularyType":"OHP","DrugName":"PEIDASURE LIQ CHOCLATE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067217"},{"Id":414978,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ CHOCLATE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067218"},{"Id":414979,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ MIX BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067282"},{"Id":414980,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ MIX BERY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067283"},{"Id":414981,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067374"},{"Id":414982,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067375"},{"Id":414983,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067378"},{"Id":414984,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067386"},{"Id":414985,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067407"},{"Id":414986,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067410"},{"Id":414987,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067411"},{"Id":414988,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067412"},{"Id":414989,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067413"},{"Id":414990,"FormularyType":"OHP","DrugName":"PEDIASUR 1.0 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067414"},{"Id":414991,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067417"},{"Id":414992,"FormularyType":"OHP","DrugName":"PEDIASUR 1.5 LIQ PEPTIDE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067418"},{"Id":414993,"FormularyType":"OHP","DrugName":"ENSURE PLANT LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067450"},{"Id":414994,"FormularyType":"OHP","DrugName":"ENSURE PLANT LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067451"},{"Id":414995,"FormularyType":"OHP","DrugName":"ENSURE PLANT LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067452"},{"Id":414996,"FormularyType":"OHP","DrugName":"ENSURE PLANT LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067453"},{"Id":414997,"FormularyType":"OHP","DrugName":"ENSURE PLANT LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067455"},{"Id":414998,"FormularyType":"OHP","DrugName":"ENSURE PLANT LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067456"},{"Id":414999,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067522"},{"Id":415000,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067523"},{"Id":415001,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067524"},{"Id":415002,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067525"},{"Id":415003,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067526"},{"Id":415004,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067527"},{"Id":415005,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ BANANA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067528"},{"Id":415006,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067529"},{"Id":415007,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067530"},{"Id":415008,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067531"},{"Id":415009,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ W/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067532"},{"Id":415010,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067533"},{"Id":415011,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067534"},{"Id":415012,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067535"},{"Id":415013,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067536"},{"Id":415014,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067537"},{"Id":415015,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067538"},{"Id":415016,"FormularyType":"OHP","DrugName":"PEDIASURE LIQ RED CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067613"},{"Id":415017,"FormularyType":"OHP","DrugName":"VITAL AF LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067642"},{"Id":415018,"FormularyType":"OHP","DrugName":"VITAL AF LIQ 1.2 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067643"},{"Id":415019,"FormularyType":"OHP","DrugName":"ENSURE SURGI LIQ BUNDLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074067655"},{"Id":415020,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BERRY FR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074067966"},{"Id":415021,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BERRY FR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074067967"},{"Id":415022,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FRUIT PU","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074067969"},{"Id":415023,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FRUIT PU","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074067970"},{"Id":415024,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068048"},{"Id":415025,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068054"},{"Id":415026,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068055"},{"Id":415027,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068057"},{"Id":415028,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068058"},{"Id":415029,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068060"},{"Id":415030,"FormularyType":"OHP","DrugName":"ENSURE COMPL LIQ STRAWBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068061"},{"Id":415031,"FormularyType":"OHP","DrugName":"TWOCAL HN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068062"},{"Id":415032,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068169"},{"Id":415033,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068170"},{"Id":415034,"FormularyType":"OHP","DrugName":"ENSURE MAX LIQ PROTEIN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068171"},{"Id":415035,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068230"},{"Id":415036,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068231"},{"Id":415037,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068232"},{"Id":415038,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068233"},{"Id":415039,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068234"},{"Id":415040,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068235"},{"Id":415041,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068236"},{"Id":415042,"FormularyType":"OHP","DrugName":"ENSURE PLUS LIQ HIGH PRO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068237"},{"Id":415043,"FormularyType":"OHP","DrugName":"ELECARE JR POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074068625"},{"Id":415044,"FormularyType":"OHP","DrugName":"ELECARE JR POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074068628"},{"Id":415045,"FormularyType":"OHP","DrugName":"ELECARE JR POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074068630"},{"Id":415046,"FormularyType":"OHP","DrugName":"ELECARE JR POW VANILLA","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"70074068631"},{"Id":415047,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068756"},{"Id":415048,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068758"},{"Id":415049,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068760"},{"Id":415050,"FormularyType":"OHP","DrugName":"PEDIASUR G&G LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068781"},{"Id":415051,"FormularyType":"OHP","DrugName":"PROTALITY LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068978"},{"Id":415052,"FormularyType":"OHP","DrugName":"PROTALITY LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068979"},{"Id":415053,"FormularyType":"OHP","DrugName":"PROTALITY LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068982"},{"Id":415054,"FormularyType":"OHP","DrugName":"PROTALITY LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068983"},{"Id":415055,"FormularyType":"OHP","DrugName":"PROTALITY LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068984"},{"Id":415056,"FormularyType":"OHP","DrugName":"PROTALITY LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074068985"},{"Id":415057,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074068995"},{"Id":415058,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL BERRY","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074068996"},{"Id":415059,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074068997"},{"Id":415060,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074068998"},{"Id":415061,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074080240"},{"Id":415062,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074080336"},{"Id":415063,"FormularyType":"OHP","DrugName":"PEDIALYTE SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"70074080365"},{"Id":415064,"FormularyType":"OHP","DrugName":"POLYCOSE LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100025000900","GenericName":"GLUCOSE POLYMERS LIQD","NDC":"70074080431"},{"Id":415065,"FormularyType":"OHP","DrugName":"OSMOLITE 1 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074080668"},{"Id":415066,"FormularyType":"OHP","DrugName":"JEVITY 1 CAL LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074080682"},{"Id":415067,"FormularyType":"OHP","DrugName":"ADVERA LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074513050"},{"Id":415068,"FormularyType":"OHP","DrugName":"ADVERA LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70074524530"},{"Id":415069,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"70092005305"},{"Id":415070,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"70092005405"},{"Id":415071,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142056","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/250ML-0.9%","NDC":"70092005605"},{"Id":415072,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.75/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142068","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.75 GM/250ML-0.9%","NDC":"70092017405"},{"Id":415073,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"70092033807"},{"Id":415074,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"70092059907"},{"Id":415075,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM/10ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E520","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 1 GM/10ML","NDC":"70092060346"},{"Id":415076,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM/20ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E530","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 2 GM/20ML","NDC":"70092060447"},{"Id":415077,"FormularyType":"OHP","DrugName":"CEFAZOL/NACL INJ 2/100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015122025","GenericName":"CEFAZOLIN SODIUM IN SODIUM CHLORIDE 0.9% IV SOLN 2 GM/100ML","NDC":"70092062203"},{"Id":415078,"FormularyType":"OHP","DrugName":"CEFAZOL/NACL INJ 3/100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015122030","GenericName":"CEFAZOLIN SODIUM IN SODIUM CHLORIDE 0.9% IV SOLN 3 GM/100ML","NDC":"70092062303"},{"Id":415079,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"70092101550"},{"Id":415080,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM/10ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E520","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 1 GM/10ML","NDC":"70092101746"},{"Id":415081,"FormularyType":"OHP","DrugName":"CEFAZOL/NACL INJ 2/100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015122025","GenericName":"CEFAZOLIN SODIUM IN SODIUM CHLORIDE 0.9% IV SOLN 2 GM/100ML","NDC":"70092101803"},{"Id":415082,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"70092105305"},{"Id":415083,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.75/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142068","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.75 GM/250ML-0.9%","NDC":"70092117405"},{"Id":415084,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM/20ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E530","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 2 GM/20ML","NDC":"70092123847"},{"Id":415085,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"70092133807"},{"Id":415086,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142024","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 750 MG/150ML-0.9%","NDC":"70092144204"},{"Id":415087,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122055","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1.25 GM/250ML-5%","NDC":"70092154817"},{"Id":415088,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"70092159907"},{"Id":415089,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM/10ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E520","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 1 GM/10ML","NDC":"70092160346"},{"Id":415090,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM/20ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E530","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 2 GM/20ML","NDC":"70092160447"},{"Id":415091,"FormularyType":"OHP","DrugName":"CEFAZOL/NACL INJ 2/100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015122025","GenericName":"CEFAZOLIN SODIUM IN SODIUM CHLORIDE 0.9% IV SOLN 2 GM/100ML","NDC":"70092162203"},{"Id":415092,"FormularyType":"OHP","DrugName":"CEFAZOL/NACL INJ 3/100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015122030","GenericName":"CEFAZOLIN SODIUM IN SODIUM CHLORIDE 0.9% IV SOLN 3 GM/100ML","NDC":"70092162303"},{"Id":415093,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"70092905305"},{"Id":415094,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"70092905405"},{"Id":415095,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142056","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/250ML-0.9%","NDC":"70092905605"},{"Id":415096,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122060","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1.5 GM/250ML-5%","NDC":"70092905817"},{"Id":415097,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.75/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142068","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.75 GM/250ML-0.9%","NDC":"70092917405"},{"Id":415098,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"70092933807"},{"Id":415099,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 750/150","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142024","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 750 MG/150ML-0.9%","NDC":"70092944204"},{"Id":415100,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122055","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1.25 GM/250ML-5%","NDC":"70092954817"},{"Id":415101,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"70092959907"},{"Id":415102,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"70095001701"},{"Id":415103,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"70095001801"},{"Id":415104,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"70095001901"},{"Id":415105,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"70095001902"},{"Id":415106,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"70095002001"},{"Id":415107,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"70095002002"},{"Id":415108,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"70095002501"},{"Id":415109,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"70095002502"},{"Id":415110,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"70095002601"},{"Id":415111,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102031","GenericName":"DESMOPRESSIN ACETATE PRESERVATIVE FREE (PF) INJ 4 MCG/ML","NDC":"70095002602"},{"Id":415112,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 40/10ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"70095003101"},{"Id":415113,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"70095005001"},{"Id":415114,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"70095005003"},{"Id":415115,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121104901"},{"Id":415116,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121104902"},{"Id":415117,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121104905"},{"Id":415118,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"70121107601"},{"Id":415119,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"70121107605"},{"Id":415120,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121116801"},{"Id":415121,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121116901"},{"Id":415122,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"70121145301"},{"Id":415123,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"70121145307"},{"Id":415124,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"70121145401"},{"Id":415125,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"70121145407"},{"Id":415126,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"70121146702"},{"Id":415127,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"70121146705"},{"Id":415128,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSY - Susp Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2515003510E620","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML","NDC":"70121148001"},{"Id":415129,"FormularyType":"OHP","DrugName":"FYLNETRA INJ 6MG/0.6","DosageForm":"SOSY - Soln Pref Syr","Strength":"6","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8240157060E520","GenericName":"PEGFILGRASTIM-PBBK SOLN PREFILLED SYRINGE 6 MG/0.6ML","NDC":"70121162701"},{"Id":415130,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165101"},{"Id":415131,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165105"},{"Id":415132,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165201"},{"Id":415133,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165301"},{"Id":415134,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165401"},{"Id":415135,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165501"},{"Id":415136,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"70121165701"},{"Id":415137,"FormularyType":"OHP","DrugName":"EXENATIDE INJ 5MCG","DosageForm":"SOPN - Soln Pen-inj","Strength":"5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717002000D220","GenericName":"EXENATIDE SOLN PEN-INJECTOR 5 MCG/0.02ML","NDC":"70121168501"},{"Id":415138,"FormularyType":"OHP","DrugName":"EXENATIDE INJ 10MCG","DosageForm":"SOPN - Soln Pen-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717002000D240","GenericName":"EXENATIDE SOLN PEN-INJECTOR 10 MCG/0.04ML","NDC":"70121168601"},{"Id":415139,"FormularyType":"OHP","DrugName":"LEUPROLIDE INJ 14 DAY","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"70121253706"},{"Id":415140,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"70156010401"},{"Id":415141,"FormularyType":"OHP","DrugName":"HYOSCYAMINE SUB 0.125MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100710","GenericName":"HYOSCYAMINE SULFATE SL TAB 0.125 MG","NDC":"70156010501"},{"Id":415142,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107220","GenericName":"HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","NDC":"70156010601"},{"Id":415143,"FormularyType":"OHP","DrugName":"INNOVACIN LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"70210000130"},{"Id":415144,"FormularyType":"OHP","DrugName":"MEKTOVI TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533520000320","GenericName":"BINIMETINIB TAB 15 MG","NDC":"70255001002"},{"Id":415145,"FormularyType":"OHP","DrugName":"BRAFTOVI CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532040000130","GenericName":"ENCORAFENIB CAP 75 MG","NDC":"70255002501"},{"Id":415146,"FormularyType":"OHP","DrugName":"BRAFTOVI CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532040000130","GenericName":"ENCORAFENIB CAP 75 MG","NDC":"70255002502"},{"Id":415147,"FormularyType":"OHP","DrugName":"BRAFTOVI CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532040000130","GenericName":"ENCORAFENIB CAP 75 MG","NDC":"70255002503"},{"Id":415148,"FormularyType":"OHP","DrugName":"BRAFTOVI CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532040000130","GenericName":"ENCORAFENIB CAP 75 MG","NDC":"70255002504"},{"Id":415149,"FormularyType":"OHP","DrugName":"PIN-AWAY SUS 144MG/ML","DosageForm":"SUSP - Suspension","Strength":"144","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000060101805","GenericName":"PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV)","NDC":"70309008002"},{"Id":415150,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"70369000101"},{"Id":415151,"FormularyType":"OHP","DrugName":"INGREZZA CAP 60MG","DosageForm":"CAPS - Capsule","Strength":"60","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380080200130","GenericName":"VALBENAZINE TOSYLATE CAP 60 MG (BASE EQUIV)","NDC":"70370106001"},{"Id":415152,"FormularyType":"OHP","DrugName":"INGREZZA CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380080200140","GenericName":"VALBENAZINE TOSYLATE CAP 80 MG (BASE EQUIV)","NDC":"70370108001"},{"Id":415153,"FormularyType":"OHP","DrugName":"INGREZZA CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380080200120","GenericName":"VALBENAZINE TOSYLATE CAP 40 MG (BASE EQUIV)","NDC":"70370204001"},{"Id":415154,"FormularyType":"OHP","DrugName":"INGREZZA CAP 40-80MG","DosageForm":"CPPK - Cap Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6238008020B220","GenericName":"VALBENAZINE TOSYLATE CAP THERAPY PACK 40 MG (7) & 80 MG (21)","NDC":"70370204806"},{"Id":415155,"FormularyType":"OHP","DrugName":"INGREZZA CAP 40MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"40","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380080206830","GenericName":"VALBENAZINE TOSYLATE CAPSULE SPRINKLE 40 MG (BASE EQUIV)","NDC":"70370404001"},{"Id":415156,"FormularyType":"OHP","DrugName":"INGREZZA CAP 60MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"60","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380080206850","GenericName":"VALBENAZINE TOSYLATE CAPSULE SPRINKLE 60 MG (BASE EQUIV)","NDC":"70370406001"},{"Id":415157,"FormularyType":"OHP","DrugName":"INGREZZA CAP 80MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"80","BrandVsGeneric":"N","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380080206870","GenericName":"VALBENAZINE TOSYLATE CAPSULE SPRINKLE 80 MG (BASE EQUIV)","NDC":"70370408001"},{"Id":415158,"FormularyType":"OHP","DrugName":"CRENESSITY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"CORTICOTROPIN-RELEASING FACTOR (CRF) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30321020000120","GenericName":"CRINECERFONT CAP 25 MG","NDC":"70370502501"},{"Id":415159,"FormularyType":"OHP","DrugName":"CRENESSITY CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"CORTICOTROPIN-RELEASING FACTOR (CRF) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30321020000130","GenericName":"CRINECERFONT CAP 50 MG","NDC":"70370505001"},{"Id":415160,"FormularyType":"OHP","DrugName":"CRENESSITY CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"CORTICOTROPIN-RELEASING FACTOR (CRF) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30321020000145","GenericName":"CRINECERFONT CAP 100 MG","NDC":"70370510001"},{"Id":415161,"FormularyType":"OHP","DrugName":"CRENESSITY SOL 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"CORTICOTROPIN-RELEASING FACTOR (CRF) RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30321020002020","GenericName":"CRINECERFONT ORAL SOLN 50 MG/ML","NDC":"70370525001"},{"Id":415162,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"70377000112"},{"Id":415163,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"70377000114"},{"Id":415164,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"70377000115"},{"Id":415165,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"70377000212"},{"Id":415166,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"70377000214"},{"Id":415167,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"70377000215"},{"Id":415168,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"70377000312"},{"Id":415169,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"70377000314"},{"Id":415170,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"70377000315"},{"Id":415171,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"70377000412"},{"Id":415172,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"70377000414"},{"Id":415173,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"70377000415"},{"Id":415174,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"70377000512"},{"Id":415175,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"70377000514"},{"Id":415176,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"70377000515"},{"Id":415177,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"70377000612"},{"Id":415178,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"70377000613"},{"Id":415179,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"70377000712"},{"Id":415180,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"70377000713"},{"Id":415181,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"70377000812"},{"Id":415182,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"70377000813"},{"Id":415183,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"70377000911"},{"Id":415184,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"70377000912"},{"Id":415185,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"70377000913"},{"Id":415186,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"70377001011"},{"Id":415187,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"70377001022"},{"Id":415188,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"70377001023"},{"Id":415189,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"70377001111"},{"Id":415190,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"70377001122"},{"Id":415191,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"70377001123"},{"Id":415192,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"70377001211"},{"Id":415193,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"70377001222"},{"Id":415194,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"70377001223"},{"Id":415195,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"70377001311"},{"Id":415196,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"70377001322"},{"Id":415197,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"70377001323"},{"Id":415198,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"70377001411"},{"Id":415199,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"70377001511"},{"Id":415200,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"70377001611"},{"Id":415201,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"70377003112"},{"Id":415202,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"70377003113"},{"Id":415203,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"70377003212"},{"Id":415204,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"70377003213"},{"Id":415205,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"70377003312"},{"Id":415206,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"70377003313"},{"Id":415207,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"70377003811"},{"Id":415208,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"70377003911"},{"Id":415209,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"70377004011"},{"Id":415210,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"70377004512"},{"Id":415211,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"70377004514"},{"Id":415212,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"70377004612"},{"Id":415213,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"70377004614"},{"Id":415214,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"70377004712"},{"Id":415215,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"70377004714"},{"Id":415216,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"70377004812"},{"Id":415217,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"70377004913"},{"Id":415218,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"70377005013"},{"Id":415219,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"70377005113"},{"Id":415220,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"70377005211"},{"Id":415221,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"70377005311"},{"Id":415222,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"70377005411"},{"Id":415223,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70377005511"},{"Id":415224,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70377005512"},{"Id":415225,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70377005513"},{"Id":415226,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70377005611"},{"Id":415227,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70377005612"},{"Id":415228,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"70377005613"},{"Id":415229,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"70377006012"},{"Id":415230,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"70377006013"},{"Id":415231,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"70377006112"},{"Id":415232,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"70377006113"},{"Id":415233,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"70377006212"},{"Id":415234,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"70377006213"},{"Id":415235,"FormularyType":"OHP","DrugName":"LABETALOL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100320","GenericName":"LABETALOL HCL TAB 400 MG","NDC":"70377006311"},{"Id":415236,"FormularyType":"OHP","DrugName":"LABETALOL TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"N","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100320","GenericName":"LABETALOL HCL TAB 400 MG","NDC":"70377006312"},{"Id":415237,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70377006611"},{"Id":415238,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"70377006711"},{"Id":415239,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"70377006811"},{"Id":415240,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000320","GenericName":"EVEROLIMUS TAB 0.25 MG","NDC":"70377006911"},{"Id":415241,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.5 MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000325","GenericName":"EVEROLIMUS TAB 0.5 MG","NDC":"70377007011"},{"Id":415242,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000330","GenericName":"EVEROLIMUS TAB 0.75 MG","NDC":"70377007111"},{"Id":415243,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70377007711"},{"Id":415244,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70377007713"},{"Id":415245,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70377007811"},{"Id":415246,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70377007813"},{"Id":415247,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70377007911"},{"Id":415248,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70377007913"},{"Id":415249,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"70377008011"},{"Id":415250,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"70377008013"},{"Id":415251,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"70377008111"},{"Id":415252,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"70377008211"},{"Id":415253,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"70377008311"},{"Id":415254,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"70377008411"},{"Id":415255,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"70377008511"},{"Id":415256,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"70377008611"},{"Id":415257,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"70377008711"},{"Id":415258,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"70377008811"},{"Id":415259,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2MG","DosageForm":"TBSO - Tablet Soluble","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007310","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 2 MG","NDC":"70377009023"},{"Id":415260,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 3MG","DosageForm":"TBSO - Tablet Soluble","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007320","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 3 MG","NDC":"70377009123"},{"Id":415261,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TBSO - Tablet Soluble","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530007340","GenericName":"EVEROLIMUS TAB FOR ORAL SUSP 5 MG","NDC":"70377009223"},{"Id":415262,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404035000335","GenericName":"EVEROLIMUS TAB 1 MG","NDC":"70377011211"},{"Id":415263,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"70377011311"},{"Id":415264,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"70377011412"},{"Id":415265,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"70377011512"},{"Id":415266,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"70377011612"},{"Id":415267,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"70377011711"},{"Id":415268,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"70377012611"},{"Id":415269,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"70377012711"},{"Id":415270,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"70393008901"},{"Id":415271,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"70393008902"},{"Id":415272,"FormularyType":"OHP","DrugName":"CARETOUCH MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"70393010201"},{"Id":415273,"FormularyType":"OHP","DrugName":"CARETOUCH MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"70393010301"},{"Id":415274,"FormularyType":"OHP","DrugName":"CARETOUCH MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"70393010401"},{"Id":415275,"FormularyType":"OHP","DrugName":"CARETOUCH MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"70393011501"},{"Id":415276,"FormularyType":"OHP","DrugName":"CARETOUCH MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"70393011601"},{"Id":415277,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"70393013101"},{"Id":415278,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"70393013401"},{"Id":415279,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"70393014001"},{"Id":415280,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"70393014201"},{"Id":415281,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"70393014301"},{"Id":415282,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"70393014401"},{"Id":415283,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"70393014501"},{"Id":415284,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"70393014601"},{"Id":415285,"FormularyType":"OHP","DrugName":"HYPO NEEDLE MIS 26GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020266325","GenericName":"NEEDLE (DISP) 26 X 1\"","NDC":"70393014701"},{"Id":415286,"FormularyType":"OHP","DrugName":"CARETOUCH MIS 27GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276330","GenericName":"NEEDLE (DISP) 27 X 1-1/2\"","NDC":"70393015101"},{"Id":415287,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906368","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 5/16\"","NDC":"70393029601"},{"Id":415288,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906382","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 5/16\"","NDC":"70393029901"},{"Id":415289,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"70393030101"},{"Id":415290,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"70393030201"},{"Id":415291,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"70393030901"},{"Id":415292,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"70393031001"},{"Id":415293,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"70393031101"},{"Id":415294,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"70393040010"},{"Id":415295,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"70393040020"},{"Id":415296,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"70393040030"},{"Id":415297,"FormularyType":"OHP","DrugName":"CARETOUCH PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"70393040040"},{"Id":415298,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"70393050101"},{"Id":415299,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"70393050201"},{"Id":415300,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"70393050301"},{"Id":415301,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"70393050401"},{"Id":415302,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"70393051701"},{"Id":415303,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"70393051801"},{"Id":415304,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"70393051901"},{"Id":415305,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"70393052001"},{"Id":415306,"FormularyType":"OHP","DrugName":"CATHETER/TIP MIS 60ML COV","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"70393054025"},{"Id":415307,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"70393055501"},{"Id":415308,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"70393055601"},{"Id":415309,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"70393055701"},{"Id":415310,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"70393055901"},{"Id":415311,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"70393056001"},{"Id":415312,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"70393056101"},{"Id":415313,"FormularyType":"OHP","DrugName":"3ML LUER LOC MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"70393056201"},{"Id":415314,"FormularyType":"OHP","DrugName":"ELIXOPHYLLIN ELX 80/15ML","DosageForm":"ELIX - Elixir","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040001010","GenericName":"THEOPHYLLINE ELIXIR 80 MG/15ML","NDC":"70408064434"},{"Id":415315,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"70436000101"},{"Id":415316,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 8MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000420","GenericName":"POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","NDC":"70436000103"},{"Id":415317,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"70436000201"},{"Id":415318,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"70436000203"},{"Id":415319,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100320","GenericName":"GALANTAMINE HYDROBROMIDE TAB 4 MG","NDC":"70436000406"},{"Id":415320,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100330","GenericName":"GALANTAMINE HYDROBROMIDE TAB 8 MG","NDC":"70436000506"},{"Id":415321,"FormularyType":"OHP","DrugName":"GALANTAMINE TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051030100340","GenericName":"GALANTAMINE HYDROBROMIDE TAB 12 MG","NDC":"70436000606"},{"Id":415322,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"70436000704"},{"Id":415323,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"70436000804"},{"Id":415324,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"70436000904"},{"Id":415325,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"70436001982"},{"Id":415326,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"70436002082"},{"Id":415327,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"70436002182"},{"Id":415328,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"70436002282"},{"Id":415329,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"70436002382"},{"Id":415330,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000310","GenericName":"TETRABENAZINE TAB 12.5 MG","NDC":"70436010109"},{"Id":415331,"FormularyType":"OHP","DrugName":"TETRABENAZIN TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MOVEMENT DISORDER DRUG THERAPY","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62380070000320","GenericName":"TETRABENAZINE TAB 25 MG","NDC":"70436010209"},{"Id":415332,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000445","GenericName":"POTASSIUM CHLORIDE TAB ER 20 MEQ (1500 MG)","NDC":"70436015301"},{"Id":415333,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000320","GenericName":"CILOSTAZOL TAB 50 MG","NDC":"70436015606"},{"Id":415334,"FormularyType":"OHP","DrugName":"CILOSTAZOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85155516000330","GenericName":"CILOSTAZOL TAB 100 MG","NDC":"70436015706"},{"Id":415335,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"70436016002"},{"Id":415336,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"70436016004"},{"Id":415337,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 2MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207020","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 2 MG","NDC":"70436016006"},{"Id":415338,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"70436016102"},{"Id":415339,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"70436016104"},{"Id":415340,"FormularyType":"OHP","DrugName":"TOLTERODINE CAP 4MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060207030","GenericName":"TOLTERODINE TARTRATE CAP ER 24HR 4 MG","NDC":"70436016106"},{"Id":415341,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"70436016601"},{"Id":415342,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"70436016602"},{"Id":415343,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"70436016701"},{"Id":415344,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"70436016702"},{"Id":415345,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"70436017223"},{"Id":415346,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"70436017323"},{"Id":415347,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"70436018301"},{"Id":415348,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"70436018302"},{"Id":415349,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"70436019101"},{"Id":415350,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107020","GenericName":"DILTIAZEM HCL CAP ER 24HR 120 MG","NDC":"70436019102"},{"Id":415351,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"70436019201"},{"Id":415352,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 180MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107030","GenericName":"DILTIAZEM HCL CAP ER 24HR 180 MG","NDC":"70436019202"},{"Id":415353,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"70436019301"},{"Id":415354,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 240MG ER","DosageForm":"CP24 - Capsule ER 24 HR","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010107040","GenericName":"DILTIAZEM HCL CAP ER 24HR 240 MG","NDC":"70436019302"},{"Id":415355,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"70436020201"},{"Id":415356,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"70436020202"},{"Id":415357,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"70436022034"},{"Id":415358,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"70436022134"},{"Id":415359,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"70436022236"},{"Id":415360,"FormularyType":"OHP","DrugName":"FLUCONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015001940","GenericName":"FLUCONAZOLE FOR SUSP 40 MG/ML","NDC":"70436022748"},{"Id":415361,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"70436022849"},{"Id":415362,"FormularyType":"OHP","DrugName":"VORICONAZOLE SUS 40MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"11407080001920","GenericName":"VORICONAZOLE FOR SUSP 40 MG/ML","NDC":"70436023039"},{"Id":415363,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"900","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002050","GenericName":"AMIODARONE HCL INJ 900 MG/18ML (50 MG/ML)","NDC":"70436023250"},{"Id":415364,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"70436023252"},{"Id":415365,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"70436023262"},{"Id":415366,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002030","GenericName":"AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","NDC":"70436023272"},{"Id":415367,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"70436023273"},{"Id":415368,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"900","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002050","GenericName":"AMIODARONE HCL INJ 900 MG/18ML (50 MG/ML)","NDC":"70436023274"},{"Id":415369,"FormularyType":"OHP","DrugName":"NERLYNX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533035100320","GenericName":"NERATINIB MALEATE TAB 40 MG (BASE EQUIVALENT)","NDC":"70437024018"},{"Id":415370,"FormularyType":"OHP","DrugName":"NERLYNX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533035100320","GenericName":"NERATINIB MALEATE TAB 40 MG (BASE EQUIVALENT)","NDC":"70437024033"},{"Id":415371,"FormularyType":"OHP","DrugName":"FLUAD INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002046E620","GenericName":"INFLUENZA VAC TYPE A&B SURFACE ANT ADJ SUSP PREF SYR 0.5 ML","NDC":"70461002503"},{"Id":415372,"FormularyType":"OHP","DrugName":"FLUAD INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002046E620","GenericName":"INFLUENZA VAC TYPE A&B SURFACE ANT ADJ SUSP PREF SYR 0.5 ML","NDC":"70461002504"},{"Id":415373,"FormularyType":"OHP","DrugName":"FLUCELVAX INJ 2025-26","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020801810","GenericName":"INFLUENZA VIRUS VAC TISS-CULT SUBUNIT IM SUSP","NDC":"70461055510"},{"Id":415374,"FormularyType":"OHP","DrugName":"FLUCELVAX INJ 2025-26","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100020801810","GenericName":"INFLUENZA VIRUS VAC TISS-CULT SUBUNIT IM SUSP","NDC":"70461055511"},{"Id":415375,"FormularyType":"OHP","DrugName":"FLUCELVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002080E620","GenericName":"INFLUENZA VIRUS VAC TISS-CULT SUBUNIT SUSP PREF SYR 0.5 ML","NDC":"70461065503"},{"Id":415376,"FormularyType":"OHP","DrugName":"FLUCELVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"3","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002080E620","GenericName":"INFLUENZA VIRUS VAC TISS-CULT SUBUNIT SUSP PREF SYR 0.5 ML","NDC":"70461065504"},{"Id":415377,"FormularyType":"OHP","DrugName":"AUDENZ INJ","DosageForm":"PRSY - Prefilled Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002077E420","GenericName":"INFLUENZA A(H5N1) TISS-CULT SUBUNT ADJUV EMUL PREF SYR 0.5ML","NDC":"70461070003"},{"Id":415378,"FormularyType":"OHP","DrugName":"AUDENZ INJ","DosageForm":"PRSY - Prefilled Syr","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710002077E420","GenericName":"INFLUENZA A(H5N1) TISS-CULT SUBUNT ADJUV EMUL PREF SYR 0.5ML","NDC":"70461070004"},{"Id":415379,"FormularyType":"OHP","DrugName":"NEUTROGENA SHA T/SAL 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"70501009650"},{"Id":415380,"FormularyType":"OHP","DrugName":"RADICAVA ORS SUS STARTER","DosageForm":"SUSP - Suspension","Strength":"105","BrandVsGeneric":"N","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74509030001820","GenericName":"EDARAVONE ORAL SUSP 105 MG/5ML","NDC":"70510232101"},{"Id":415381,"FormularyType":"OHP","DrugName":"RADICAVA ORS SUS STARTER","DosageForm":"SUSP - Suspension","Strength":"105","BrandVsGeneric":"N","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74509030001820","GenericName":"EDARAVONE ORAL SUSP 105 MG/5ML","NDC":"70510232102"},{"Id":415382,"FormularyType":"OHP","DrugName":"RADICAVA ORS SUS 105/5ML","DosageForm":"SUSP - Suspension","Strength":"105","BrandVsGeneric":"N","DrugCategory":"NEUROMUSCULAR AGENTS","DrugSubClass":"ALS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"74509030001820","GenericName":"EDARAVONE ORAL SUSP 105 MG/5ML","NDC":"70510232201"},{"Id":415383,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"70512010030"},{"Id":415384,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075103720","GenericName":"HYDROCORTISONE ACETATE CREAM 1%","NDC":"70512010130"},{"Id":415385,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"70512010230"},{"Id":415386,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"70512010330"},{"Id":415387,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"70512010610"},{"Id":415388,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"70512052005"},{"Id":415389,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"70512075010"},{"Id":415390,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"70512078010"},{"Id":415391,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"70512078210"},{"Id":415392,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"70512078460"},{"Id":415393,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"70512079005"},{"Id":415394,"FormularyType":"OHP","DrugName":"KETOROLAC SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805035102020","GenericName":"KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","NDC":"70512079010"},{"Id":415395,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"70512079305"},{"Id":415396,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"70512079310"},{"Id":415397,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000310","GenericName":"IBUPROFEN TAB 300 MG","NDC":"70512079490"},{"Id":415398,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70512084001"},{"Id":415399,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70512084025"},{"Id":415400,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084105"},{"Id":415401,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084106"},{"Id":415402,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084110"},{"Id":415403,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084111"},{"Id":415404,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084125"},{"Id":415405,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084126"},{"Id":415406,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084150"},{"Id":415407,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084151"},{"Id":415408,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084160"},{"Id":415409,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"70512084161"},{"Id":415410,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"70512085214"},{"Id":415411,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"70512085360"},{"Id":415412,"FormularyType":"OHP","DrugName":"CABERGOLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"PROLACTIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30402020000320","GenericName":"CABERGOLINE TAB 0.5 MG","NDC":"70512086008"},{"Id":415413,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"70512087210"},{"Id":415414,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"70512090030"},{"Id":415415,"FormularyType":"OHP","DrugName":"TYMLOS INJ","DosageForm":"SOPN - Soln Pen-inj","Strength":"3120","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3004400500D230","GenericName":"ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML","NDC":"70539000101"},{"Id":415416,"FormularyType":"OHP","DrugName":"TYMLOS INJ","DosageForm":"SOPN - Soln Pen-inj","Strength":"3120","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3004400500D230","GenericName":"ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML","NDC":"70539000102"},{"Id":415417,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"70594002301"},{"Id":415418,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"70594002304"},{"Id":415419,"FormularyType":"OHP","DrugName":"COLISTIMETH INJ 150MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"POLYMYXINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16100004202132","GenericName":"COLISTIMETHATE SOD FOR INJ 150 MG (COLISTIN BASE ACTIVITY)","NDC":"70594002309"},{"Id":415420,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500/100","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102040","GenericName":"VANCOMYCIN HCL IV SOLN 500 MG/100ML (BASE EQUIVALENT)","NDC":"70594004101"},{"Id":415421,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500/100","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102040","GenericName":"VANCOMYCIN HCL IV SOLN 500 MG/100ML (BASE EQUIVALENT)","NDC":"70594004103"},{"Id":415422,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1G/200ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102058","GenericName":"VANCOMYCIN HCL IV SOLN 1000 MG/200ML (BASE EQUIVALENT)","NDC":"70594004201"},{"Id":415423,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1G/200ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102058","GenericName":"VANCOMYCIN HCL IV SOLN 1000 MG/200ML (BASE EQUIVALENT)","NDC":"70594004203"},{"Id":415424,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5/300","DosageForm":"SOLN - Solution","Strength":"1500","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102068","GenericName":"VANCOMYCIN HCL IV SOLN 1500 MG/300ML (BASE EQUIVALENT)","NDC":"70594004301"},{"Id":415425,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.5/300","DosageForm":"SOLN - Solution","Strength":"1500","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102068","GenericName":"VANCOMYCIN HCL IV SOLN 1500 MG/300ML (BASE EQUIVALENT)","NDC":"70594004302"},{"Id":415426,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 2G/400ML","DosageForm":"SOLN - Solution","Strength":"2000","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102073","GenericName":"VANCOMYCIN HCL IV SOLN 2000 MG/400ML (BASE EQUIVALENT)","NDC":"70594004401"},{"Id":415427,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 2G/400ML","DosageForm":"SOLN - Solution","Strength":"2000","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102073","GenericName":"VANCOMYCIN HCL IV SOLN 2000 MG/400ML (BASE EQUIVALENT)","NDC":"70594004402"},{"Id":415428,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"70594004501"},{"Id":415429,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"70594004502"},{"Id":415430,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"70594004601"},{"Id":415431,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"70594004602"},{"Id":415432,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"70594004701"},{"Id":415433,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"70594004801"},{"Id":415434,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750/150","DosageForm":"SOLN - Solution","Strength":"750","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102053","GenericName":"VANCOMYCIN HCL IV SOLN 750 MG/150ML (BASE EQUIVALENT)","NDC":"70594005601"},{"Id":415435,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750/150","DosageForm":"SOLN - Solution","Strength":"750","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102053","GenericName":"VANCOMYCIN HCL IV SOLN 750 MG/150ML (BASE EQUIVALENT)","NDC":"70594005603"},{"Id":415436,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"1250","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102063","GenericName":"VANCOMYCIN HCL IV SOLN 1250 MG/250ML (BASE EQUIVALENT)","NDC":"70594005701"},{"Id":415437,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"1250","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102063","GenericName":"VANCOMYCIN HCL IV SOLN 1250 MG/250ML (BASE EQUIVALENT)","NDC":"70594005702"},{"Id":415438,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.75/350","DosageForm":"SOLN - Solution","Strength":"1750","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102072","GenericName":"VANCOMYCIN HCL IV SOLN 1750 MG/350ML (BASE EQUIVALENT)","NDC":"70594005801"},{"Id":415439,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.75/350","DosageForm":"SOLN - Solution","Strength":"1750","BrandVsGeneric":"M","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102072","GenericName":"VANCOMYCIN HCL IV SOLN 1750 MG/350ML (BASE EQUIVALENT)","NDC":"70594005802"},{"Id":415440,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/.5ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"70594006801"},{"Id":415441,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/.5ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070102010","GenericName":"SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","NDC":"70594006802"},{"Id":415442,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"70594007501"},{"Id":415443,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"70594007502"},{"Id":415444,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"70594007601"},{"Id":415445,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"70594007602"},{"Id":415446,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"70594012201"},{"Id":415447,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"70594012202"},{"Id":415448,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"70594012301"},{"Id":415449,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"70594012302"},{"Id":415450,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"70655000206"},{"Id":415451,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 200","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012010","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 200 MG/100ML","NDC":"70655000210"},{"Id":415452,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"70655008806"},{"Id":415453,"FormularyType":"OHP","DrugName":"FLUCONAZOLE/ INJ NACL 400","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015012020","GenericName":"FLUCONAZOLE IN NACL 0.9% INJ 400 MG/200ML","NDC":"70655008810"},{"Id":415454,"FormularyType":"OHP","DrugName":"FT ANTIFUNGA CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"70677100001"},{"Id":415455,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"70677100201"},{"Id":415456,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"70677100301"},{"Id":415457,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677100701"},{"Id":415458,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677100702"},{"Id":415459,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677100703"},{"Id":415460,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677100704"},{"Id":415461,"FormularyType":"OHP","DrugName":"FT ALLR RLF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"70677100801"},{"Id":415462,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70677100901"},{"Id":415463,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70677100902"},{"Id":415464,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70677100903"},{"Id":415465,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70677101401"},{"Id":415466,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70677101402"},{"Id":415467,"FormularyType":"OHP","DrugName":"FT ALRGY RLF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"70677101501"},{"Id":415468,"FormularyType":"OHP","DrugName":"FT ALRGY RLF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"70677101502"},{"Id":415469,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"70677101601"},{"Id":415470,"FormularyType":"OHP","DrugName":"FT NSL DECON TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"70677101701"},{"Id":415471,"FormularyType":"OHP","DrugName":"FT NSL DECON TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"70677101702"},{"Id":415472,"FormularyType":"OHP","DrugName":"FT NSL DECON TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"70677101703"},{"Id":415473,"FormularyType":"OHP","DrugName":"DECONGESTANT TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"70677101901"},{"Id":415474,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677102201"},{"Id":415475,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677102202"},{"Id":415476,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677102203"},{"Id":415477,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677102204"},{"Id":415478,"FormularyType":"OHP","DrugName":"FT 24 HOUR SPR 55MCG","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"70677102301"},{"Id":415479,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"70677104201"},{"Id":415480,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677104701"},{"Id":415481,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677105301"},{"Id":415482,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677105302"},{"Id":415483,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"70677105303"},{"Id":415484,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"70677105701"},{"Id":415485,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"70677105801"},{"Id":415486,"FormularyType":"OHP","DrugName":"FT ANTACID SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"70677106301"},{"Id":415487,"FormularyType":"OHP","DrugName":"FT ANTACID SUS ANTIGAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"70677106601"},{"Id":415488,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70677106801"},{"Id":415489,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70677106802"},{"Id":415490,"FormularyType":"OHP","DrugName":"FT SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"70677106901"},{"Id":415491,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300305","GenericName":"DOCUSATE SODIUM TAB 100 MG","NDC":"70677107101"},{"Id":415492,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"70677107201"},{"Id":415493,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"70677107301"},{"Id":415494,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"70677107401"},{"Id":415495,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"70677107402"},{"Id":415496,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"70677107501"},{"Id":415497,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70677107601"},{"Id":415498,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"70677107901"},{"Id":415499,"FormularyType":"OHP","DrugName":"FT ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"70677108101"},{"Id":415500,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"70677108201"},{"Id":415501,"FormularyType":"OHP","DrugName":"FT FIBER LAX TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"70677108301"},{"Id":415502,"FormularyType":"OHP","DrugName":"FT LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70677108601"},{"Id":415503,"FormularyType":"OHP","DrugName":"FT LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70677108602"},{"Id":415504,"FormularyType":"OHP","DrugName":"FT LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"70677108603"},{"Id":415505,"FormularyType":"OHP","DrugName":"FT MOTION TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"70677108701"},{"Id":415506,"FormularyType":"OHP","DrugName":"FT MOTION TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"70677108801"},{"Id":415507,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"70677108901"},{"Id":415508,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"70677108902"},{"Id":415509,"FormularyType":"OHP","DrugName":"FT MINERAL ENE","DosageForm":"ENEM - Enema","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010005110","GenericName":"MINERAL OIL ENEMA","NDC":"70677109001"},{"Id":415510,"FormularyType":"OHP","DrugName":"FT GNTLE LAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"70677109101"},{"Id":415511,"FormularyType":"OHP","DrugName":"FT STL SOFT TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"70677109401"},{"Id":415512,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"70677109501"},{"Id":415513,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"70677109502"},{"Id":415514,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"70677109601"},{"Id":415515,"FormularyType":"OHP","DrugName":"FT SENNA LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"70677109701"},{"Id":415516,"FormularyType":"OHP","DrugName":"FT ACID REDU CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70677109901"},{"Id":415517,"FormularyType":"OHP","DrugName":"FT ACID REDU CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70677109902"},{"Id":415518,"FormularyType":"OHP","DrugName":"FT ACID REDU CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"70677109903"},{"Id":415519,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70677110101"},{"Id":415520,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70677110102"},{"Id":415521,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"70677110201"},{"Id":415522,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"70677110202"},{"Id":415523,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"70677110203"},{"Id":415524,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70677110901"},{"Id":415525,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70677110902"},{"Id":415526,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70677110903"},{"Id":415527,"FormularyType":"OHP","DrugName":"FT CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"70677110904"},{"Id":415528,"FormularyType":"OHP","DrugName":"FT MINERAL OIL","DosageForm":"OIL - Oil","Strength":"99.9","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"70677111001"},{"Id":415529,"FormularyType":"OHP","DrugName":"FT MAG CITRA SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"70677111101"},{"Id":415530,"FormularyType":"OHP","DrugName":"FT MAG CITRA SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"70677111201"},{"Id":415531,"FormularyType":"OHP","DrugName":"FT IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70677111301"},{"Id":415532,"FormularyType":"OHP","DrugName":"FT IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70677111401"},{"Id":415533,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70677111501"},{"Id":415534,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70677111502"},{"Id":415535,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70677111601"},{"Id":415536,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70677111701"},{"Id":415537,"FormularyType":"OHP","DrugName":"FT IBU CHILD SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"70677111801"},{"Id":415538,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"70677111901"},{"Id":415539,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677112001"},{"Id":415540,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677112002"},{"Id":415541,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70677112101"},{"Id":415542,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"70677112201"},{"Id":415543,"FormularyType":"OHP","DrugName":"FT 8HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"70677112301"},{"Id":415544,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677112401"},{"Id":415545,"FormularyType":"OHP","DrugName":"FT ARTHRITIS GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"70677112501"},{"Id":415546,"FormularyType":"OHP","DrugName":"FT CHLD PAIN CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"70677112701"},{"Id":415547,"FormularyType":"OHP","DrugName":"FT NITE SLP TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"70677112801"},{"Id":415548,"FormularyType":"OHP","DrugName":"FT SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"70677112901"},{"Id":415549,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"70677113101"},{"Id":415550,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113201"},{"Id":415551,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113202"},{"Id":415552,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113203"},{"Id":415553,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113204"},{"Id":415554,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113205"},{"Id":415555,"FormularyType":"OHP","DrugName":"FT MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"70677113301"},{"Id":415556,"FormularyType":"OHP","DrugName":"FT ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"70677113401"},{"Id":415557,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113601"},{"Id":415558,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113602"},{"Id":415559,"FormularyType":"OHP","DrugName":"FT IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677113603"},{"Id":415560,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677113801"},{"Id":415561,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677113802"},{"Id":415562,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677113803"},{"Id":415563,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677113805"},{"Id":415564,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677113901"},{"Id":415565,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"70677114201"},{"Id":415566,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"70677114301"},{"Id":415567,"FormularyType":"OHP","DrugName":"FT IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"70677114401"},{"Id":415568,"FormularyType":"OHP","DrugName":"IBUPROFEN IB CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"70677114501"},{"Id":415569,"FormularyType":"OHP","DrugName":"FT IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"70677114601"},{"Id":415570,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70677115001"},{"Id":415571,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70677115002"},{"Id":415572,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70677115003"},{"Id":415573,"FormularyType":"OHP","DrugName":"FT SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"70677115101"},{"Id":415574,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"70677115501"},{"Id":415575,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"70677115601"},{"Id":415576,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70677116401"},{"Id":415577,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70677116501"},{"Id":415578,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70677116601"},{"Id":415579,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70677116602"},{"Id":415580,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70677116701"},{"Id":415581,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70677116702"},{"Id":415582,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70677117001"},{"Id":415583,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70677117101"},{"Id":415584,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"70677117201"},{"Id":415585,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"70677117301"},{"Id":415586,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"70677117401"},{"Id":415587,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"70677117501"},{"Id":415588,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"70677117601"},{"Id":415589,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"70677117701"},{"Id":415590,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"70677117801"},{"Id":415591,"FormularyType":"OHP","DrugName":"FT NICOTINE LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"70677117901"},{"Id":415592,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"70677118001"},{"Id":415593,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"70677118101"},{"Id":415594,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"70677118201"},{"Id":415595,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"70677118401"},{"Id":415596,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"70677118901"},{"Id":415597,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"70677119201"},{"Id":415598,"FormularyType":"OHP","DrugName":"FT NICOTINE GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"70677119301"},{"Id":415599,"FormularyType":"OHP","DrugName":"FT ANTIBIOTI OIN","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"70677121101"},{"Id":415600,"FormularyType":"OHP","DrugName":"FT ITCH RELF OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"70677121401"},{"Id":415601,"FormularyType":"OHP","DrugName":"FT ITCH RELF CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"70677121501"},{"Id":415602,"FormularyType":"OHP","DrugName":"FT ITCH RELF CRE /ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"70677121601"},{"Id":415603,"FormularyType":"OHP","DrugName":"FT ITCH RELF CRE /ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"70677121602"},{"Id":415604,"FormularyType":"OHP","DrugName":"FT TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"70677121701"},{"Id":415605,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"70677121901"},{"Id":415606,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"70677122201"},{"Id":415607,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"70677122501"},{"Id":415608,"FormularyType":"OHP","DrugName":"FT MICONAZ 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"70677122601"},{"Id":415609,"FormularyType":"OHP","DrugName":"FT CLOTRIMAZ CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"70677123101"},{"Id":415610,"FormularyType":"OHP","DrugName":"FT ALRGY CHD SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"70677123601"},{"Id":415611,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"70677123801"},{"Id":415612,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70677123901"},{"Id":415613,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677124101"},{"Id":415614,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677124201"},{"Id":415615,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"70677124401"},{"Id":415616,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"70677125301"},{"Id":415617,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70677125601"},{"Id":415618,"FormularyType":"OHP","DrugName":"FT ALRGY RLF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"70677125602"},{"Id":415619,"FormularyType":"OHP","DrugName":"FT ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"70677126001"},{"Id":415620,"FormularyType":"OHP","DrugName":"FT 7 DAY VAG CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003705","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 1%","NDC":"70677126201"},{"Id":415621,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"70677126401"},{"Id":415622,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"70677126501"},{"Id":415623,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"70677126601"},{"Id":415624,"FormularyType":"OHP","DrugName":"FT NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"70677126602"},{"Id":415625,"FormularyType":"OHP","DrugName":"FT ALRGY RLF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"70677126801"},{"Id":415626,"FormularyType":"OHP","DrugName":"FT ALRGY RLF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"70677126802"},{"Id":415627,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUP 120MG","DosageForm":"SUPP - Suppository","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005205","GenericName":"ACETAMINOPHEN SUPPOS 120 MG","NDC":"70677127001"},{"Id":415628,"FormularyType":"OHP","DrugName":"PAIN RELIEVE SUP 650MG","DosageForm":"SUPP - Suppository","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010005220","GenericName":"ACETAMINOPHEN SUPPOS 650 MG","NDC":"70677127101"},{"Id":415629,"FormularyType":"OHP","DrugName":"FT PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70677127601"},{"Id":415630,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677127901"},{"Id":415631,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677127902"},{"Id":415632,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677127903"},{"Id":415633,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677127904"},{"Id":415634,"FormularyType":"OHP","DrugName":"FT ALLERGY TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"70677127905"},{"Id":415635,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"70677128001"},{"Id":415636,"FormularyType":"OHP","DrugName":"FT IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70677128201"},{"Id":415637,"FormularyType":"OHP","DrugName":"FT NALOXONE SPR 4MG","DosageForm":"LIQD - Liquid","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100920","GenericName":"NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","NDC":"70677128301"},{"Id":415638,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"70677128601"},{"Id":415639,"FormularyType":"OHP","DrugName":"FT MOTION CHW 25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000510","GenericName":"MECLIZINE HCL CHEW TAB 25 MG","NDC":"70677129001"},{"Id":415640,"FormularyType":"OHP","DrugName":"FT ARTHRITIS GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"70677129301"},{"Id":415641,"FormularyType":"OHP","DrugName":"NORETH/ETHIN CHW FE 1/20","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"70700010184"},{"Id":415642,"FormularyType":"OHP","DrugName":"NORETH/ETHIN CHW FE 1/20","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610512","GenericName":"NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","NDC":"70700010185"},{"Id":415643,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70700010615"},{"Id":415644,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70700010616"},{"Id":415645,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70700010617"},{"Id":415646,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70700010618"},{"Id":415647,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"70700010915"},{"Id":415648,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"70700010916"},{"Id":415649,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"70700010917"},{"Id":415650,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"70700010918"},{"Id":415651,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"70700011221"},{"Id":415652,"FormularyType":"OHP","DrugName":"ISIBLOOM TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"70700011384"},{"Id":415653,"FormularyType":"OHP","DrugName":"ISIBLOOM TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002100320","GenericName":"DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"70700011385"},{"Id":415654,"FormularyType":"OHP","DrugName":"LORYNA TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"70700011484"},{"Id":415655,"FormularyType":"OHP","DrugName":"LORYNA TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"70700011485"},{"Id":415656,"FormularyType":"OHP","DrugName":"SYEDA TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"70700011584"},{"Id":415657,"FormularyType":"OHP","DrugName":"SYEDA TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"70700011585"},{"Id":415658,"FormularyType":"OHP","DrugName":"ALTAVERA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"70700011684"},{"Id":415659,"FormularyType":"OHP","DrugName":"ALTAVERA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400310","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","NDC":"70700011685"},{"Id":415660,"FormularyType":"OHP","DrugName":"INTROVALE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"70700011787"},{"Id":415661,"FormularyType":"OHP","DrugName":"VIENVA TAB 0.1-20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"70700011884"},{"Id":415662,"FormularyType":"OHP","DrugName":"VIENVA TAB 0.1-20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002400305","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","NDC":"70700011885"},{"Id":415663,"FormularyType":"OHP","DrugName":"ESTARYLLA TAB 0.25-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"70700011984"},{"Id":415664,"FormularyType":"OHP","DrugName":"ESTARYLLA TAB 0.25-35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002950310","GenericName":"NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","NDC":"70700011985"},{"Id":415665,"FormularyType":"OHP","DrugName":"TRI-LO TAB ESTARYLL","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"70700012084"},{"Id":415666,"FormularyType":"OHP","DrugName":"TRI-LO TAB ESTARYLL","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300310","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","NDC":"70700012085"},{"Id":415667,"FormularyType":"OHP","DrugName":"TRI-ESTARYLL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"70700012184"},{"Id":415668,"FormularyType":"OHP","DrugName":"TRI-ESTARYLL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992002300320","GenericName":"NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","NDC":"70700012185"},{"Id":415669,"FormularyType":"OHP","DrugName":"VOLNEA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"70700012284"},{"Id":415670,"FormularyType":"OHP","DrugName":"VOLNEA TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"70700012285"},{"Id":415671,"FormularyType":"OHP","DrugName":"JAIMIESS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"70700012387"},{"Id":415672,"FormularyType":"OHP","DrugName":"LOJAIMIESS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"70700012487"},{"Id":415673,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"70700015001"},{"Id":415674,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"70700015010"},{"Id":415675,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"70700015030"},{"Id":415676,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"70700015110"},{"Id":415677,"FormularyType":"OHP","DrugName":"ENILLORING MIS","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"70700015611"},{"Id":415678,"FormularyType":"OHP","DrugName":"ENILLORING MIS","DosageForm":"RING - Ring","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - VAGINAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25970002309020","GenericName":"ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.12-0.015 MG/24HR","NDC":"70700015691"},{"Id":415679,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"70700015701"},{"Id":415680,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"70700015801"},{"Id":415681,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"70700015901"},{"Id":415682,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000120","GenericName":"PROGESTERONE CAP 100 MG","NDC":"70700016201"},{"Id":415683,"FormularyType":"OHP","DrugName":"PROGESTERONE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000040000140","GenericName":"PROGESTERONE CAP 200 MG","NDC":"70700016301"},{"Id":415684,"FormularyType":"OHP","DrugName":"LEVONORGESTR TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"70700016406"},{"Id":415685,"FormularyType":"OHP","DrugName":"JAIMIESS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"70700020687"},{"Id":415686,"FormularyType":"OHP","DrugName":"JAIMIESS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300330","GenericName":"LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","NDC":"70700020693"},{"Id":415687,"FormularyType":"OHP","DrugName":"LOJAIMIESS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"70700020787"},{"Id":415688,"FormularyType":"OHP","DrugName":"LOJAIMIESS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300315","GenericName":"LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","NDC":"70700020793"},{"Id":415689,"FormularyType":"OHP","DrugName":"INTROVALE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"70700020887"},{"Id":415690,"FormularyType":"OHP","DrugName":"INTROVALE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300320","GenericName":"LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","NDC":"70700020888"},{"Id":415691,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"70700026305"},{"Id":415692,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"70700026330"},{"Id":415693,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"70700026390"},{"Id":415694,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"70700026894"},{"Id":415695,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"70700026899"},{"Id":415696,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"70700026930"},{"Id":415697,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"70700027030"},{"Id":415698,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"70700027130"},{"Id":415699,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"70700027205"},{"Id":415700,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"70700027210"},{"Id":415701,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"70700027230"},{"Id":415702,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 10MG/ML","DosageForm":"OIL - Oil","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201705","GenericName":"ESTRADIOL VALERATE IM IN OIL 10 MG/ML","NDC":"70700027322"},{"Id":415703,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 20MG/ML","DosageForm":"OIL - Oil","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201710","GenericName":"ESTRADIOL VALERATE IM IN OIL 20 MG/ML","NDC":"70700027422"},{"Id":415704,"FormularyType":"OHP","DrugName":"ESTRAD VAL INJ 40MG/ML","DosageForm":"OIL - Oil","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035201715","GenericName":"ESTRADIOL VALERATE IM IN OIL 40 MG/ML","NDC":"70700027522"},{"Id":415705,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102010","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML","NDC":"70700028822"},{"Id":415706,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"70700028922"},{"Id":415707,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"70700029022"},{"Id":415708,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"70700030101"},{"Id":415709,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"70700030201"},{"Id":415710,"FormularyType":"OHP","DrugName":"ABIGALE LO TAB 0.5-0.1","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120305","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","NDC":"70700030384"},{"Id":415711,"FormularyType":"OHP","DrugName":"ABIGALE LO TAB 0.5-0.1","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120305","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","NDC":"70700030385"},{"Id":415712,"FormularyType":"OHP","DrugName":"VALTYA 1/35 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"70700030484"},{"Id":415713,"FormularyType":"OHP","DrugName":"VALTYA 1/35 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"70700030485"},{"Id":415714,"FormularyType":"OHP","DrugName":"VALTYA 1/50 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200320","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG","NDC":"70700030584"},{"Id":415715,"FormularyType":"OHP","DrugName":"VALTYA 1/50 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200320","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG","NDC":"70700030585"},{"Id":415716,"FormularyType":"OHP","DrugName":"GALBRIELA CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600540","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG","NDC":"70700030684"},{"Id":415717,"FormularyType":"OHP","DrugName":"GALBRIELA CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600540","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG","NDC":"70700030685"},{"Id":415718,"FormularyType":"OHP","DrugName":"FEIRZA TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"70700030784"},{"Id":415719,"FormularyType":"OHP","DrugName":"FEIRZA TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"70700030785"},{"Id":415720,"FormularyType":"OHP","DrugName":"XELRIA FE CHW 0.4MG-35","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600520","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","NDC":"70700030884"},{"Id":415721,"FormularyType":"OHP","DrugName":"XELRIA FE CHW 0.4MG-35","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003600520","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","NDC":"70700030885"},{"Id":415722,"FormularyType":"OHP","DrugName":"FEIRZA TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"70700030984"},{"Id":415723,"FormularyType":"OHP","DrugName":"FEIRZA TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"70700030985"},{"Id":415724,"FormularyType":"OHP","DrugName":"XARAH FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992003300340","GenericName":"NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG","NDC":"70700031084"},{"Id":415725,"FormularyType":"OHP","DrugName":"XARAH FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992003300340","GenericName":"NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG","NDC":"70700031085"},{"Id":415726,"FormularyType":"OHP","DrugName":"ROSYRAH TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25993002300350","GenericName":"LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG","NDC":"70700031287"},{"Id":415727,"FormularyType":"OHP","DrugName":"LUIZZA 1/20 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"70700031378"},{"Id":415728,"FormularyType":"OHP","DrugName":"LUIZZA 1/20 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"70700031379"},{"Id":415729,"FormularyType":"OHP","DrugName":"LUIZZA TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"70700031478"},{"Id":415730,"FormularyType":"OHP","DrugName":"LUIZZA TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"70700031479"},{"Id":415731,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"70700031522"},{"Id":415732,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"70700031525"},{"Id":415733,"FormularyType":"OHP","DrugName":"MEDROXYPR AC INJ 150MG/ML","DosageForm":"SUSP - Suspension","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - INJECTABLE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25150035101820","GenericName":"MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","NDC":"70700031527"},{"Id":415734,"FormularyType":"OHP","DrugName":"ORQUIDEA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"70700031684"},{"Id":415735,"FormularyType":"OHP","DrugName":"ORQUIDEA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"70700031685"},{"Id":415736,"FormularyType":"OHP","DrugName":"MELEYA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"70700031784"},{"Id":415737,"FormularyType":"OHP","DrugName":"MELEYA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"70700031785"},{"Id":415738,"FormularyType":"OHP","DrugName":"GALLIFREY TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PROGESTINS","DrugSubClass":"PROGESTINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"26000030100305","GenericName":"NORETHINDRONE ACETATE TAB 5 MG","NDC":"70700032650"},{"Id":415739,"FormularyType":"OHP","DrugName":"ABIGALE TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"70700033084"},{"Id":415740,"FormularyType":"OHP","DrugName":"ABIGALE TAB 1-0.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGEN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24993002120310","GenericName":"ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","NDC":"70700033085"},{"Id":415741,"FormularyType":"OHP","DrugName":"PHYRAGO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"70709015120"},{"Id":415742,"FormularyType":"OHP","DrugName":"PHYRAGO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"70709015250"},{"Id":415743,"FormularyType":"OHP","DrugName":"PHYRAGO TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"70709015370"},{"Id":415744,"FormularyType":"OHP","DrugName":"PHYRAGO TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"70709015480"},{"Id":415745,"FormularyType":"OHP","DrugName":"PHYRAGO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"70709015510"},{"Id":415746,"FormularyType":"OHP","DrugName":"PHYRAGO TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"70709015614"},{"Id":415747,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"70710100802"},{"Id":415748,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"70710100902"},{"Id":415749,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"70710101002"},{"Id":415750,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"70710101401"},{"Id":415751,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"70710101403"},{"Id":415752,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"70710102208"},{"Id":415753,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"70710102308"},{"Id":415754,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"70710102408"},{"Id":415755,"FormularyType":"OHP","DrugName":"ISOTRETINOIN CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"70710102508"},{"Id":415756,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"70710103007"},{"Id":415757,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"70710103107"},{"Id":415758,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"70710103207"},{"Id":415759,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"70710103308"},{"Id":415760,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"70710103408"},{"Id":415761,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"70710103508"},{"Id":415762,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"70710106101"},{"Id":415763,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"70710106201"},{"Id":415764,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"70710111000"},{"Id":415765,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"70710111001"},{"Id":415766,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000305","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 50 MG","NDC":"70710112101"},{"Id":415767,"FormularyType":"OHP","DrugName":"DOXYCYC MONO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020000310","GenericName":"DOXYCYCLINE MONOHYDRATE TAB 100 MG","NDC":"70710112307"},{"Id":415768,"FormularyType":"OHP","DrugName":"URSODIOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000325","GenericName":"URSODIOL TAB 250 MG","NDC":"70710112701"},{"Id":415769,"FormularyType":"OHP","DrugName":"URSODIOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000350","GenericName":"URSODIOL TAB 500 MG","NDC":"70710112801"},{"Id":415770,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"70710113703"},{"Id":415771,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"70710113801"},{"Id":415772,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"70710113803"},{"Id":415773,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"70710113907"},{"Id":415774,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"70710113908"},{"Id":415775,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"70710114001"},{"Id":415776,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"70710114003"},{"Id":415777,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"70710114801"},{"Id":415778,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"70710114901"},{"Id":415779,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"70710115001"},{"Id":415780,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"70710115101"},{"Id":415781,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"70710115703"},{"Id":415782,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"70710115803"},{"Id":415783,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007520","GenericName":"MIRABEGRON TAB ER 24 HR 25 MG","NDC":"70710115903"},{"Id":415784,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007520","GenericName":"MIRABEGRON TAB ER 24 HR 25 MG","NDC":"70710115909"},{"Id":415785,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007530","GenericName":"MIRABEGRON TAB ER 24 HR 50 MG","NDC":"70710116003"},{"Id":415786,"FormularyType":"OHP","DrugName":"MIRABEGRON TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"64","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54200050007530","GenericName":"MIRABEGRON TAB ER 24 HR 50 MG","NDC":"70710116009"},{"Id":415787,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"70710116100"},{"Id":415788,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000305","GenericName":"MECLIZINE HCL TAB 12.5 MG","NDC":"70710116101"},{"Id":415789,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"70710116200"},{"Id":415790,"FormularyType":"OHP","DrugName":"MECLIZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"70710116201"},{"Id":415791,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"70710116506"},{"Id":415792,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100310","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","NDC":"70710116701"},{"Id":415793,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100320","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","NDC":"70710116801"},{"Id":415794,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"70710117903"},{"Id":415795,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"70710118003"},{"Id":415796,"FormularyType":"OHP","DrugName":"NORELGE/ETHI DIS 150/35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"70710119001"},{"Id":415797,"FormularyType":"OHP","DrugName":"NORELGE/ETHI DIS 150/35","DosageForm":"PTWK - Patch Weekly","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - TRANSDERMAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25960002508820","GenericName":"NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","NDC":"70710119003"},{"Id":415798,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"70710119101"},{"Id":415799,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.025MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.025","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008705","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","NDC":"70710119108"},{"Id":415800,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"70710119201"},{"Id":415801,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.0375MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.0375","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008710","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","NDC":"70710119208"},{"Id":415802,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"70710119301"},{"Id":415803,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.05MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008720","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","NDC":"70710119308"},{"Id":415804,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"70710119401"},{"Id":415805,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.075MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008730","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","NDC":"70710119408"},{"Id":415806,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"70710119501"},{"Id":415807,"FormularyType":"OHP","DrugName":"ESTRADIOL DIS 0.1MG","DosageForm":"PTTW - Patch Twice Weekly","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035008750","GenericName":"ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","NDC":"70710119508"},{"Id":415808,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"70710120900"},{"Id":415809,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"70710120901"},{"Id":415810,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"70710121001"},{"Id":415811,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"70710121005"},{"Id":415812,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"70710123301"},{"Id":415813,"FormularyType":"OHP","DrugName":"BETAMETH DIP CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020003705","GenericName":"BETAMETHASONE DIPROPIONATE CREAM 0.05%","NDC":"70710123304"},{"Id":415814,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"70710127206"},{"Id":415815,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"70710127306"},{"Id":415816,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"70710127406"},{"Id":415817,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"70710127503"},{"Id":415818,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"70710127603"},{"Id":415819,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"70710127703"},{"Id":415820,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"70710128403"},{"Id":415821,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"70710128500"},{"Id":415822,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"70710128501"},{"Id":415823,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"70710128505"},{"Id":415824,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"70710128600"},{"Id":415825,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"70710128601"},{"Id":415826,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"70710128605"},{"Id":415827,"FormularyType":"OHP","DrugName":"VIGABATRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170085000320","GenericName":"VIGABATRIN TAB 500 MG","NDC":"70710128701"},{"Id":415828,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000310","GenericName":"TRIAZOLAM TAB 0.25 MG","NDC":"70710128901"},{"Id":415829,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000310","GenericName":"TRIAZOLAM TAB 0.25 MG","NDC":"70710128905"},{"Id":415830,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"70710130206"},{"Id":415831,"FormularyType":"OHP","DrugName":"MESALAMINE SUP 1000MG","DosageForm":"SUPP - Suppository","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030005240","GenericName":"MESALAMINE SUPPOS 1000 MG","NDC":"70710130207"},{"Id":415832,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"70710134401"},{"Id":415833,"FormularyType":"OHP","DrugName":"RAMELTEON TAB 8MG","DosageForm":"TABS - Tablet","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"SELECTIVE MELATONIN RECEPTOR AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60250060000320","GenericName":"RAMELTEON TAB 8 MG","NDC":"70710134403"},{"Id":415834,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"70710135101"},{"Id":415835,"FormularyType":"OHP","DrugName":"COLCHICINE TAB 0.6MG","DosageForm":"TABS - Tablet","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000020000310","GenericName":"COLCHICINE TAB 0.6 MG","NDC":"70710135103"},{"Id":415836,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"70710135901"},{"Id":415837,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"70710135906"},{"Id":415838,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 100-150","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300308","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG","NDC":"70710136403"},{"Id":415839,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 133-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300312","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 133-200 MG","NDC":"70710136503"},{"Id":415840,"FormularyType":"OHP","DrugName":"EMTR/TEN DF TAB 167-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300316","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG","NDC":"70710136603"},{"Id":415841,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"70710136703"},{"Id":415842,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100310","GenericName":"ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","NDC":"70710139503"},{"Id":415843,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100320","GenericName":"ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","NDC":"70710139603"},{"Id":415844,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100330","GenericName":"ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","NDC":"70710139703"},{"Id":415845,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100340","GenericName":"ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","NDC":"70710139803"},{"Id":415846,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70710140101"},{"Id":415847,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70710140102"},{"Id":415848,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70710140103"},{"Id":415849,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"70710140104"},{"Id":415850,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 100/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001920","GenericName":"AZITHROMYCIN FOR SUSP 100 MG/5ML","NDC":"70710145701"},{"Id":415851,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"70710145802"},{"Id":415852,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"70710145902"},{"Id":415853,"FormularyType":"OHP","DrugName":"AZITHROMYCIN SUS 200/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010001930","GenericName":"AZITHROMYCIN FOR SUSP 200 MG/5ML","NDC":"70710146002"},{"Id":415854,"FormularyType":"OHP","DrugName":"COLESTIPOL TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"BILE ACID SEQUESTRANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39100020100320","GenericName":"COLESTIPOL HCL TAB 1 GM","NDC":"70710146707"},{"Id":415855,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100320","GenericName":"IVABRADINE HCL TAB 5 MG (BASE EQUIV)","NDC":"70710147106"},{"Id":415856,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100330","GenericName":"IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","NDC":"70710147206"},{"Id":415857,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"70710148301"},{"Id":415858,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"70710151406"},{"Id":415859,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 2.5/0.5","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102020","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","NDC":"70710151409"},{"Id":415860,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"70710151506"},{"Id":415861,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 5/0.4ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102035","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","NDC":"70710151509"},{"Id":415862,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"70710151606"},{"Id":415863,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 7.5/0.6","DosageForm":"SOLN - Solution","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102040","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","NDC":"70710151609"},{"Id":415864,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"70710151706"},{"Id":415865,"FormularyType":"OHP","DrugName":"FONDAPARINUX INJ 10/0.8ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83103030102045","GenericName":"FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","NDC":"70710151709"},{"Id":415866,"FormularyType":"OHP","DrugName":"TRIAZOLAM TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201040000305","GenericName":"TRIAZOLAM TAB 0.125 MG","NDC":"70710152101"},{"Id":415867,"FormularyType":"OHP","DrugName":"ACETAZOLAMID CAP 500MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010006920","GenericName":"ACETAZOLAMIDE CAP ER 12HR 500 MG","NDC":"70710159101"},{"Id":415868,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"70710159207"},{"Id":415869,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"70710160901"},{"Id":415870,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"70710161306"},{"Id":415871,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"70710161406"},{"Id":415872,"FormularyType":"OHP","DrugName":"BALSALAZIDE CAP 750MG","DosageForm":"CAPS - Capsule","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500020100120","GenericName":"BALSALAZIDE DISODIUM CAP 750 MG","NDC":"70710162601"},{"Id":415873,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70710164305"},{"Id":415874,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70710164307"},{"Id":415875,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70710164401"},{"Id":415876,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70710164405"},{"Id":415877,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70710166301"},{"Id":415878,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70710166307"},{"Id":415879,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70710166406"},{"Id":415880,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70710166407"},{"Id":415881,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70710166501"},{"Id":415882,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70710166505"},{"Id":415883,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000308","GenericName":"BACLOFEN TAB 15 MG","NDC":"70710166601"},{"Id":415884,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"70710166701"},{"Id":415885,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"70710166801"},{"Id":415886,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70710168300"},{"Id":415887,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70710168301"},{"Id":415888,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"70710168400"},{"Id":415889,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"70710168401"},{"Id":415890,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"70710168405"},{"Id":415891,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 0.5GM","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100110","GenericName":"ICOSAPENT ETHYL CAP 0.5 GM","NDC":"70710173804"},{"Id":415892,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"70710174106"},{"Id":415893,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"70710174206"},{"Id":415894,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"70710174306"},{"Id":415895,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"70710174403"},{"Id":415896,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"70710174503"},{"Id":415897,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"70710174603"},{"Id":415898,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"70710175706"},{"Id":415899,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"70710175806"},{"Id":415900,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"70710175906"},{"Id":415901,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"70710176006"},{"Id":415902,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"70710176106"},{"Id":415903,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"70710176206"},{"Id":415904,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"70710176306"},{"Id":415905,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"70710177000"},{"Id":415906,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"70710177009"},{"Id":415907,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70710177200"},{"Id":415908,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70710177209"},{"Id":415909,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70710177500"},{"Id":415910,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70710177509"},{"Id":415911,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70710177700"},{"Id":415912,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70710177709"},{"Id":415913,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"70710183201"},{"Id":415914,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"70710183301"},{"Id":415915,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 200MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102107","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 200 MCG","NDC":"70710183401"},{"Id":415916,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 500MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102112","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 500 MCG","NDC":"70710183501"},{"Id":415917,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"70710188601"},{"Id":415918,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"70710188606"},{"Id":415919,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000320","GenericName":"MARAVIROC TAB 150 MG","NDC":"70710193006"},{"Id":415920,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000330","GenericName":"MARAVIROC TAB 300 MG","NDC":"70710193106"},{"Id":415921,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70710193705"},{"Id":415922,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70710193707"},{"Id":415923,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000307","GenericName":"ALLOPURINOL TAB 200 MG","NDC":"70710200909"},{"Id":415924,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100340","GenericName":"SEVELAMER HCL TAB 800 MG","NDC":"70710205808"},{"Id":415925,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 2.5MG","DosageForm":"GEL - Gel","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004030","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG","NDC":"70710207802"},{"Id":415926,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 10MG","DosageForm":"GEL - Gel","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004040","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG","NDC":"70710207902"},{"Id":415927,"FormularyType":"OHP","DrugName":"DIAZEPAM GEL 20MG","DosageForm":"GEL - Gel","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100030004060","GenericName":"DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG","NDC":"70710208002"},{"Id":415928,"FormularyType":"OHP","DrugName":"PENTIPS MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"70714342901"},{"Id":415929,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"70714343001"},{"Id":415930,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"70714344001"},{"Id":415931,"FormularyType":"OHP","DrugName":"PENTIPS MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"70714345001"},{"Id":415932,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"70748012511"},{"Id":415933,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"70748012513"},{"Id":415934,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"70748012749"},{"Id":415935,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"70748012849"},{"Id":415936,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000310","GenericName":"LEFLUNOMIDE TAB 10 MG","NDC":"70748012906"},{"Id":415937,"FormularyType":"OHP","DrugName":"LEFLUNOMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"PYRIMIDINE SYNTHESIS INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66280050000320","GenericName":"LEFLUNOMIDE TAB 20 MG","NDC":"70748013006"},{"Id":415938,"FormularyType":"OHP","DrugName":"SEVELAM HCL TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070100340","GenericName":"SEVELAMER HCL TAB 800 MG","NDC":"70748017326"},{"Id":415939,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"70748019507"},{"Id":415940,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"70748019607"},{"Id":415941,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"70748019707"},{"Id":415942,"FormularyType":"OHP","DrugName":"DASATINIB TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000320","GenericName":"DASATINIB TAB 20 MG","NDC":"70748020807"},{"Id":415943,"FormularyType":"OHP","DrugName":"DASATINIB TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000340","GenericName":"DASATINIB TAB 50 MG","NDC":"70748020907"},{"Id":415944,"FormularyType":"OHP","DrugName":"DASATINIB TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000350","GenericName":"DASATINIB TAB 70 MG","NDC":"70748021007"},{"Id":415945,"FormularyType":"OHP","DrugName":"DASATINIB TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000354","GenericName":"DASATINIB TAB 80 MG","NDC":"70748021106"},{"Id":415946,"FormularyType":"OHP","DrugName":"DASATINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000360","GenericName":"DASATINIB TAB 100 MG","NDC":"70748021206"},{"Id":415947,"FormularyType":"OHP","DrugName":"DASATINIB TAB 140MG","DosageForm":"TABS - Tablet","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531820000380","GenericName":"DASATINIB TAB 140 MG","NDC":"70748021306"},{"Id":415948,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"70748023806"},{"Id":415949,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"70748023906"},{"Id":415950,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 15MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B710","GenericName":"TOLVAPTAN TAB THERAPY PACK 15 MG","NDC":"70748024011"},{"Id":415951,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 15MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B710","GenericName":"TOLVAPTAN TAB THERAPY PACK 15 MG","NDC":"70748024013"},{"Id":415952,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 30-15MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B720","GenericName":"TOLVAPTAN TAB THERAPY PACK 30 & 15 MG","NDC":"70748024111"},{"Id":415953,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 30-15MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B720","GenericName":"TOLVAPTAN TAB THERAPY PACK 30 & 15 MG","NDC":"70748024113"},{"Id":415954,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 45-15MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B725","GenericName":"TOLVAPTAN TAB THERAPY PACK 45 & 15 MG","NDC":"70748024211"},{"Id":415955,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 45-15MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B725","GenericName":"TOLVAPTAN TAB THERAPY PACK 45 & 15 MG","NDC":"70748024213"},{"Id":415956,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 60-30MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B735","GenericName":"TOLVAPTAN TAB THERAPY PACK 60 & 30 MG","NDC":"70748024311"},{"Id":415957,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 60-30MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B735","GenericName":"TOLVAPTAN TAB THERAPY PACK 60 & 30 MG","NDC":"70748024313"},{"Id":415958,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 90-30MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B745","GenericName":"TOLVAPTAN TAB THERAPY PACK 90 & 30 MG","NDC":"70748024411"},{"Id":415959,"FormularyType":"OHP","DrugName":"TOLVAPTAN PAK 90-30MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3045406000B745","GenericName":"TOLVAPTAN TAB THERAPY PACK 90 & 30 MG","NDC":"70748024413"},{"Id":415960,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"70748025807"},{"Id":415961,"FormularyType":"OHP","DrugName":"GLUCAGON INJ 1MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300010002105","GenericName":"GLUCAGON FOR INJ 1 MG","NDC":"70748031101"},{"Id":415962,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"70748032301"},{"Id":415963,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"70748032302"},{"Id":415964,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"70748032310"},{"Id":415965,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 0.25/ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"70748032311"},{"Id":415966,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"70748033202"},{"Id":415967,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"70748033203"},{"Id":415968,"FormularyType":"OHP","DrugName":"PREDNISOLONE SUS 1% OP","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86300050101815","GenericName":"PREDNISOLONE ACETATE OPHTH SUSP 1%","NDC":"70748033204"},{"Id":415969,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"70748033601"},{"Id":415970,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"70748034602"},{"Id":415971,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"70748034603"},{"Id":415972,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"70752010112"},{"Id":415973,"FormularyType":"OHP","DrugName":"ALBUTEROL SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010101205","GenericName":"ALBUTEROL SULFATE SYRUP 2 MG/5ML","NDC":"70752010212"},{"Id":415974,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"70752010406"},{"Id":415975,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"70752010710"},{"Id":415976,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"70752010711"},{"Id":415977,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"70752012310"},{"Id":415978,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100305","GenericName":"BENZTROPINE MESYLATE TAB 0.5 MG","NDC":"70752012311"},{"Id":415979,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"70752012410"},{"Id":415980,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100310","GenericName":"BENZTROPINE MESYLATE TAB 1 MG","NDC":"70752012411"},{"Id":415981,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"70752012510"},{"Id":415982,"FormularyType":"OHP","DrugName":"BENZTROPINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100010100315","GenericName":"BENZTROPINE MESYLATE TAB 2 MG","NDC":"70752012511"},{"Id":415983,"FormularyType":"OHP","DrugName":"TRIAMCINOLON LOT 0.025%","DosageForm":"LOTN - Lotion","Strength":"0.025","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104105","GenericName":"TRIAMCINOLONE ACETONIDE LOTION 0.025%","NDC":"70752012905"},{"Id":415984,"FormularyType":"OHP","DrugName":"TRIAMCINOLON LOT 0.1%","DosageForm":"LOTN - Lotion","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104110","GenericName":"TRIAMCINOLONE ACETONIDE LOTION 0.1%","NDC":"70752013005"},{"Id":415985,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102020","GenericName":"METHYLPHENIDATE HCL SOLN 5 MG/5ML","NDC":"70752013114"},{"Id":415986,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102030","GenericName":"METHYLPHENIDATE HCL SOLN 10 MG/5ML","NDC":"70752013214"},{"Id":415987,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"70752013610"},{"Id":415988,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"70752013614"},{"Id":415989,"FormularyType":"OHP","DrugName":"OXYCODONE CON 100/5ML","DosageForm":"CONC - Concentrate","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075101320","GenericName":"OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML)","NDC":"70752013703"},{"Id":415990,"FormularyType":"OHP","DrugName":"PROMETHAZINE SOL 6.25/5ML","DosageForm":"SOLN - Solution","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PHENOTHIAZINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"2","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41400020102060","GenericName":"PROMETHAZINE HCL ORAL SOLN 6.25 MG/5ML","NDC":"70752013812"},{"Id":415991,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"70752015304"},{"Id":415992,"FormularyType":"OHP","DrugName":"CLOBETASOL SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025102005","GenericName":"CLOBETASOL PROPIONATE SOLN 0.05%","NDC":"70752015320"},{"Id":415993,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"70752015405"},{"Id":415994,"FormularyType":"OHP","DrugName":"PROPYLTHIOUR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300020000310","GenericName":"PROPYLTHIOURACIL TAB 50 MG","NDC":"70752017110"},{"Id":415995,"FormularyType":"OHP","DrugName":"CYPROHEPTAD SYP 2MG/5ML","DosageForm":"SYRP - Syrup","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020101210","GenericName":"CYPROHEPTADINE HCL SYRUP 2 MG/5ML","NDC":"70752018512"},{"Id":415996,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"70752020312"},{"Id":415997,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"70752023110"},{"Id":415998,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"70752023111"},{"Id":415999,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"70756001011"},{"Id":416000,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"70756001111"},{"Id":416001,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"70756001112"},{"Id":416002,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"70756001311"},{"Id":416003,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"70756001402"},{"Id":416004,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"70756001405"},{"Id":416005,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"70756001411"},{"Id":416006,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"70756001611"},{"Id":416007,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"70756002011"},{"Id":416008,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"70756002012"},{"Id":416009,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"70756004911"},{"Id":416010,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"70756005011"},{"Id":416011,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70756005111"},{"Id":416012,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"70756005112"},{"Id":416013,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"70756005211"},{"Id":416014,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"70756005212"},{"Id":416015,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"70756007911"},{"Id":416016,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"70756008011"},{"Id":416017,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"70756008051"},{"Id":416018,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"70756008111"},{"Id":416019,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"70756008151"},{"Id":416020,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"70756008511"},{"Id":416021,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"70756009411"},{"Id":416022,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"70756009412"},{"Id":416023,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"70756009511"},{"Id":416024,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"70756009512"},{"Id":416025,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"70756021451"},{"Id":416026,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"70756021490"},{"Id":416027,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"70756021551"},{"Id":416028,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"70756021590"},{"Id":416029,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70756024712"},{"Id":416030,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70756024751"},{"Id":416031,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"70756024790"},{"Id":416032,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70756024812"},{"Id":416033,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70756024851"},{"Id":416034,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"70756024890"},{"Id":416035,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70756024912"},{"Id":416036,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70756024951"},{"Id":416037,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"70756024990"},{"Id":416038,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"70756025051"},{"Id":416039,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"70756025090"},{"Id":416040,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"70756028811"},{"Id":416041,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"70756028812"},{"Id":416042,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"70756028911"},{"Id":416043,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"70756028912"},{"Id":416044,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"70756028951"},{"Id":416045,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"70756029611"},{"Id":416046,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"70756029651"},{"Id":416047,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"70756029711"},{"Id":416048,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"70756029811"},{"Id":416049,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"70756029851"},{"Id":416050,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"70756031230"},{"Id":416051,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"70756031330"},{"Id":416052,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"70756031430"},{"Id":416053,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"70756040411"},{"Id":416054,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100110","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG","NDC":"70756041011"},{"Id":416055,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"70756041111"},{"Id":416056,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"70756041211"},{"Id":416057,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70756042911"},{"Id":416058,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70756042912"},{"Id":416059,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"70756043011"},{"Id":416060,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"70756043012"},{"Id":416061,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"70756044011"},{"Id":416062,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"70756060456"},{"Id":416063,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70756060505"},{"Id":416064,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70756060525"},{"Id":416065,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70756060605"},{"Id":416066,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"70756060685"},{"Id":416067,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"70756060730"},{"Id":416068,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"70756060915"},{"Id":416069,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"70756061030"},{"Id":416070,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70756063525"},{"Id":416071,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"70756063581"},{"Id":416072,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"70756063825"},{"Id":416073,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"70756065030"},{"Id":416074,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70756065125"},{"Id":416075,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70756065225"},{"Id":416076,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"70756065335"},{"Id":416077,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"70756065415"},{"Id":416078,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"70756065530"},{"Id":416079,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"70756065615"},{"Id":416080,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"70756065730"},{"Id":416081,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"70756065810"},{"Id":416082,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"70756065825"},{"Id":416083,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 3%","DosageForm":"NEBU - Nebulization solution","Strength":"3","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002530","GenericName":"SODIUM CHLORIDE SOLN NEBU 3%","NDC":"70756066360"},{"Id":416084,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 7%","DosageForm":"NEBU - Nebulization solution","Strength":"7","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002535","GenericName":"SODIUM CHLORIDE SOLN NEBU 7%","NDC":"70756066460"},{"Id":416085,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"70756070360"},{"Id":416086,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"70756070460"},{"Id":416087,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"70756072011"},{"Id":416088,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"70756072111"},{"Id":416089,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 15MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006510","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","NDC":"70756080630"},{"Id":416090,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"70756080730"},{"Id":416091,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"70756080751"},{"Id":416092,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"70756080790"},{"Id":416093,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"70756081230"},{"Id":416094,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"70756081290"},{"Id":416095,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"70756081330"},{"Id":416096,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"70756081390"},{"Id":416097,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"70756081430"},{"Id":416098,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"70756081490"},{"Id":416099,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"70756081560"},{"Id":416100,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"70756081622"},{"Id":416101,"FormularyType":"OHP","DrugName":"TOSYMRA SOL 10MG","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002020","GenericName":"SUMATRIPTAN NASAL SPRAY 10 MG/ACT","NDC":"70792081259"},{"Id":416102,"FormularyType":"OHP","DrugName":"TOSYMRA SOL 10MG","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002020","GenericName":"SUMATRIPTAN NASAL SPRAY 10 MG/ACT","NDC":"70792081261"},{"Id":416103,"FormularyType":"OHP","DrugName":"TOSYMRA SOL 10MG","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002020","GenericName":"SUMATRIPTAN NASAL SPRAY 10 MG/ACT","NDC":"70792081289"},{"Id":416104,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70795012001"},{"Id":416105,"FormularyType":"OHP","DrugName":"ACETAMINOPHE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"70795012025"},{"Id":416106,"FormularyType":"OHP","DrugName":"LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"70795101001"},{"Id":416107,"FormularyType":"OHP","DrugName":"LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"70795101005"},{"Id":416108,"FormularyType":"OHP","DrugName":"LAXATIVE SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"70795101008"},{"Id":416109,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100305","GenericName":"PHENAZOPYRIDINE HCL TAB 100 MG","NDC":"70795124100"},{"Id":416110,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100310","GenericName":"PHENAZOPYRIDINE HCL TAB 200 MG","NDC":"70795125200"},{"Id":416111,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"70860012541"},{"Id":416112,"FormularyType":"OHP","DrugName":"AZITHROMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MACROLIDES","DrugSubClass":"AZITHROMYCIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"03400010002120","GenericName":"AZITHROMYCIN IV FOR SOLN 500 MG","NDC":"70860012566"},{"Id":416113,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"70868090190"},{"Id":416114,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"70868091010"},{"Id":416115,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"70868092021"},{"Id":416116,"FormularyType":"OHP","DrugName":"NEONATAL PLS TAB 27-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"70898011501"},{"Id":416117,"FormularyType":"OHP","DrugName":"NEONATAL TAB COMPLTE","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"70898022001"},{"Id":416118,"FormularyType":"OHP","DrugName":"BREATHE EASE MIS METER","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"70914003700"},{"Id":416119,"FormularyType":"OHP","DrugName":"FT IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"70939095763"},{"Id":416120,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"70954000510"},{"Id":416121,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"70954000520"},{"Id":416122,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045200330","GenericName":"OXYBUTYNIN CHLORIDE TAB 5 MG","NDC":"70954000530"},{"Id":416123,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70954001910"},{"Id":416124,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70954001920"},{"Id":416125,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"70954001950"},{"Id":416126,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"70954002010"},{"Id":416127,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"70954002020"},{"Id":416128,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"70954002110"},{"Id":416129,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"70954002120"},{"Id":416130,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"70954003330"},{"Id":416131,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"70954003430"},{"Id":416132,"FormularyType":"OHP","DrugName":"RIFABUTIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000075000120","GenericName":"RIFABUTIN CAP 150 MG","NDC":"70954004110"},{"Id":416133,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"70954005110"},{"Id":416134,"FormularyType":"OHP","DrugName":"FELBAMATE SUS 600/5ML","DosageForm":"SUSP - Suspension","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020001810","GenericName":"FELBAMATE SUSP 600 MG/5ML","NDC":"70954005120"},{"Id":416135,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"70954005210"},{"Id":416136,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"70954005310"},{"Id":416137,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"70954005410"},{"Id":416138,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"70954005610"},{"Id":416139,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000305","GenericName":"PREDNISONE TAB 1 MG","NDC":"70954005620"},{"Id":416140,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000310","GenericName":"PREDNISONE TAB 2.5 MG","NDC":"70954005710"},{"Id":416141,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"70954005810"},{"Id":416142,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000315","GenericName":"PREDNISONE TAB 5 MG","NDC":"70954005820"},{"Id":416143,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B705","GenericName":"PREDNISONE TAB THERAPY PACK 5 MG (21)","NDC":"70954005830"},{"Id":416144,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B710","GenericName":"PREDNISONE TAB THERAPY PACK 5 MG (48)","NDC":"70954005840"},{"Id":416145,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"70954005910"},{"Id":416146,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000320","GenericName":"PREDNISONE TAB 10 MG","NDC":"70954005920"},{"Id":416147,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 10MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B720","GenericName":"PREDNISONE TAB THERAPY PACK 10 MG (21)","NDC":"70954005930"},{"Id":416148,"FormularyType":"OHP","DrugName":"PREDNISONE PAK 10MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2210004500B725","GenericName":"PREDNISONE TAB THERAPY PACK 10 MG (48)","NDC":"70954005940"},{"Id":416149,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"70954006010"},{"Id":416150,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"70954006020"},{"Id":416151,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000325","GenericName":"PREDNISONE TAB 20 MG","NDC":"70954006030"},{"Id":416152,"FormularyType":"OHP","DrugName":"PREDNISONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100045000335","GenericName":"PREDNISONE TAB 50 MG","NDC":"70954006110"},{"Id":416153,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"70954008510"},{"Id":416154,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000310","GenericName":"CHLORZOXAZONE TAB 500 MG","NDC":"70954008520"},{"Id":416155,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"70954013510"},{"Id":416156,"FormularyType":"OHP","DrugName":"DAPSONE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000310","GenericName":"DAPSONE TAB 25 MG","NDC":"70954013520"},{"Id":416157,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"70954013610"},{"Id":416158,"FormularyType":"OHP","DrugName":"DAPSONE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LEPROSTATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16300010000320","GenericName":"DAPSONE TAB 100 MG","NDC":"70954013620"},{"Id":416159,"FormularyType":"OHP","DrugName":"LEVOCARNITIN SOL 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045102010","GenericName":"LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)","NDC":"70954013910"},{"Id":416160,"FormularyType":"OHP","DrugName":"LEVOCARNITIN SOL 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045102010","GenericName":"LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)","NDC":"70954014010"},{"Id":416161,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"70954014810"},{"Id":416162,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"70954018810"},{"Id":416163,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"70954020110"},{"Id":416164,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"70954020120"},{"Id":416165,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"70954020210"},{"Id":416166,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"70954020220"},{"Id":416167,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100320","GenericName":"TRIHEXYPHENIDYL HCL TAB 5 MG","NDC":"70954021110"},{"Id":416168,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100320","GenericName":"TRIHEXYPHENIDYL HCL TAB 5 MG","NDC":"70954021120"},{"Id":416169,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100310","GenericName":"TRIHEXYPHENIDYL HCL TAB 2 MG","NDC":"70954021210"},{"Id":416170,"FormularyType":"OHP","DrugName":"TRIHEXYPHEN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73100070100310","GenericName":"TRIHEXYPHENIDYL HCL TAB 2 MG","NDC":"70954021220"},{"Id":416171,"FormularyType":"OHP","DrugName":"METHSUXIMIDE CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"SUCCINIMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72400020000110","GenericName":"METHSUXIMIDE CAP 300 MG","NDC":"70954022810"},{"Id":416172,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020001810","GenericName":"CARBAMAZEPINE SUSP 100 MG/5ML","NDC":"70954024010"},{"Id":416173,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"70954025220"},{"Id":416174,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"70954025230"},{"Id":416175,"FormularyType":"OHP","DrugName":"SMZ-TMP SUS 200-40/5","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE MISC. - COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16990002301810","GenericName":"SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","NDC":"70954025810"},{"Id":416176,"FormularyType":"OHP","DrugName":"DICYCLOMINE SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010102050","GenericName":"DICYCLOMINE HCL ORAL SOLN 10 MG/5ML","NDC":"70954026110"},{"Id":416177,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"70954031610"},{"Id":416178,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 50-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100310","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","NDC":"70954039010"},{"Id":416179,"FormularyType":"OHP","DrugName":"ATENOL/CHLOR TAB 100-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002100320","GenericName":"ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","NDC":"70954039110"},{"Id":416180,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"70954039810"},{"Id":416181,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"70954039910"},{"Id":416182,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"70954040110"},{"Id":416183,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"70954040210"},{"Id":416184,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"70954040310"},{"Id":416185,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"70954040410"},{"Id":416186,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"70954041210"},{"Id":416187,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"70954041230"},{"Id":416188,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"70954041240"},{"Id":416189,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"70954041310"},{"Id":416190,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"70954041330"},{"Id":416191,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"70954041340"},{"Id":416192,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"70954041410"},{"Id":416193,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"70954041430"},{"Id":416194,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"70954041440"},{"Id":416195,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000310","GenericName":"MISOPROSTOL TAB 100 MCG","NDC":"70954044310"},{"Id":416196,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000310","GenericName":"MISOPROSTOL TAB 100 MCG","NDC":"70954044320"},{"Id":416197,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"70954044410"},{"Id":416198,"FormularyType":"OHP","DrugName":"MISOPROSTOL TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ULCER DRUGS - PROSTAGLANDINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49250030000320","GenericName":"MISOPROSTOL TAB 200 MCG","NDC":"70954044420"},{"Id":416199,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"70954045510"},{"Id":416200,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"70954045520"},{"Id":416201,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"70954045610"},{"Id":416202,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"70954045620"},{"Id":416203,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"70954048410"},{"Id":416204,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"70954048420"},{"Id":416205,"FormularyType":"OHP","DrugName":"PYRAZINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000070000310","GenericName":"PYRAZINAMIDE TAB 500 MG","NDC":"70954048430"},{"Id":416206,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"70954048810"},{"Id":416207,"FormularyType":"OHP","DrugName":"LEVOCARNITIN TAB 330MG","DosageForm":"TABS - Tablet","Strength":"330","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045100330","GenericName":"LEVOCARNITINE TAB 330 MG","NDC":"70954049210"},{"Id":416208,"FormularyType":"OHP","DrugName":"SELEGILINE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100120","GenericName":"SELEGILINE HCL CAP 5 MG","NDC":"70954050410"},{"Id":416209,"FormularyType":"OHP","DrugName":"SELEGILINE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100120","GenericName":"SELEGILINE HCL CAP 5 MG","NDC":"70954050420"},{"Id":416210,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"70954051810"},{"Id":416211,"FormularyType":"OHP","DrugName":"TRIMETHOPRIM TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000055000305","GenericName":"TRIMETHOPRIM TAB 100 MG","NDC":"70954054110"},{"Id":416212,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000303","GenericName":"ESTRADIOL TAB 0.5 MG","NDC":"70954056410"},{"Id":416213,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"70954056510"},{"Id":416214,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"70954056520"},{"Id":416215,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"70954056610"},{"Id":416216,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"70954056620"},{"Id":416217,"FormularyType":"OHP","DrugName":"INDOMETHACIN SUS 25MG/5ML","DosageForm":"SUSP - Suspension","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030001805","GenericName":"INDOMETHACIN SUSP 25 MG/5ML","NDC":"70954063710"},{"Id":416218,"FormularyType":"OHP","DrugName":"KETOCONAZOLE SHA 2%","DosageForm":"SHAM - Shampoo","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004510","GenericName":"KETOCONAZOLE SHAMPOO 2%","NDC":"70954066210"},{"Id":416219,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"70954066810"},{"Id":416220,"FormularyType":"OHP","DrugName":"PENTOXIFYLLI TAB 400MG ER","DosageForm":"TBCR - Tablet ER","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATORHEOLOGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85200010000410","GenericName":"PENTOXIFYLLINE TAB ER 400 MG","NDC":"70954066820"},{"Id":416221,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100305","GenericName":"PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","NDC":"70954068810"},{"Id":416222,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"70954068910"},{"Id":416223,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"70954078410"},{"Id":416224,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"70954078420"},{"Id":416225,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"70954078510"},{"Id":416226,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"70954078520"},{"Id":416227,"FormularyType":"OHP","DrugName":"SOVUNA TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"70954080420"},{"Id":416228,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN SOL 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002050","GenericName":"LEVOFLOXACIN ORAL SOLN 25 MG/ML","NDC":"70954085210"},{"Id":416229,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN SOL 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002050","GenericName":"LEVOFLOXACIN ORAL SOLN 25 MG/ML","NDC":"70954085220"},{"Id":416230,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN SOL 25MG/ML","DosageForm":"SOLN - Solution","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034002050","GenericName":"LEVOFLOXACIN ORAL SOLN 25 MG/ML","NDC":"70954085230"},{"Id":416231,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"70954086930"},{"Id":416232,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"70954087010"},{"Id":416233,"FormularyType":"OHP","DrugName":"DEXAMETHASON ELX 0.5/5ML","DosageForm":"ELIX - Elixir","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020001005","GenericName":"DEXAMETHASONE ELIXIR 0.5 MG/5ML","NDC":"70954087210"},{"Id":416234,"FormularyType":"OHP","DrugName":"ANAGRELIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85156010100120","GenericName":"ANAGRELIDE HCL CAP 0.5 MG","NDC":"70954087910"},{"Id":416235,"FormularyType":"OHP","DrugName":"ANAGRELIDE CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85156010100130","GenericName":"ANAGRELIDE HCL CAP 1 MG","NDC":"70954088110"},{"Id":416236,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"70954089610"},{"Id":416237,"FormularyType":"OHP","DrugName":"MEGESTROL AC SUS 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21404020101810","GenericName":"MEGESTROL ACETATE SUSP 40 MG/ML","NDC":"70954089620"},{"Id":416238,"FormularyType":"OHP","DrugName":"HYDROXYZINE SOL 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"70954091210"},{"Id":416239,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"70954097520"},{"Id":416240,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"70954097530"},{"Id":416241,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"70954097620"},{"Id":416242,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"70954097630"},{"Id":416243,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"70954097720"},{"Id":416244,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"70954097730"},{"Id":416245,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"70954097810"},{"Id":416246,"FormularyType":"OHP","DrugName":"BROMOCRIPTIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200020100305","GenericName":"BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"70954097820"},{"Id":416247,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"71052020001"},{"Id":416248,"FormularyType":"OHP","DrugName":"HYDROXYPROG POW CAPROATE","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CHEMICALS","DrugSubClass":"BULK CHEMICALS - H'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"96568812502900","GenericName":"HYDROXYPROGESTERONE CAPROATE (BULK) POWDER","NDC":"71052020005"},{"Id":416249,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10/0.7ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"7210006000D530","GenericName":"MIDAZOLAM SOLUTION AUTO-INJECTOR 10 MG/0.7ML","NDC":"71053059501"},{"Id":416250,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 10/0.7ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"7210006000D530","GenericName":"MIDAZOLAM SOLUTION AUTO-INJECTOR 10 MG/0.7ML","NDC":"71053059503"},{"Id":416251,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"71085007203"},{"Id":416252,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"71085007204"},{"Id":416253,"FormularyType":"OHP","DrugName":"SODIUM FLUOR GEL 1.1%","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"71085007402"},{"Id":416254,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"71085007660"},{"Id":416255,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"71085007704"},{"Id":416256,"FormularyType":"OHP","DrugName":"SODIUM FLUOR GEL 1.1%","DosageForm":"GEL - Gel","Strength":"1.1","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"DENTAL PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"21","AgeMaxUnit":"Y","GenericProductIdentifier":"88402020004020","GenericName":"SODIUM FLUORIDE GEL 1.1% (0.5% F)","NDC":"71085007902"},{"Id":416257,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"71093011104"},{"Id":416258,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"71093011105"},{"Id":416259,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"71093011204"},{"Id":416260,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"71093011205"},{"Id":416261,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"71093011904"},{"Id":416262,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"71093011905"},{"Id":416263,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"71093011906"},{"Id":416264,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"71093012004"},{"Id":416265,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"71093012005"},{"Id":416266,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"71093012104"},{"Id":416267,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"71093012105"},{"Id":416268,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"71093012204"},{"Id":416269,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"71093012205"},{"Id":416270,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"71093012312"},{"Id":416271,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"71093012405"},{"Id":416272,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"71093012412"},{"Id":416273,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"71093012512"},{"Id":416274,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"71093012602"},{"Id":416275,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"71093012701"},{"Id":416276,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"71093012703"},{"Id":416277,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"71093012705"},{"Id":416278,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"71093012706"},{"Id":416279,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"71093012801"},{"Id":416280,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"71093012803"},{"Id":416281,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"71093012805"},{"Id":416282,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"71093012806"},{"Id":416283,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"71093013204"},{"Id":416284,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"71093013205"},{"Id":416285,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"71093013206"},{"Id":416286,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"71093013304"},{"Id":416287,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"71093013305"},{"Id":416288,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"71093013404"},{"Id":416289,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"71093013405"},{"Id":416290,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"71093014004"},{"Id":416291,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"71093014005"},{"Id":416292,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"71093014104"},{"Id":416293,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"71093014105"},{"Id":416294,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"71093014413"},{"Id":416295,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"71093014603"},{"Id":416296,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"71093014605"},{"Id":416297,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"71093014703"},{"Id":416298,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"71093014706"},{"Id":416299,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"71093014803"},{"Id":416300,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"71093014806"},{"Id":416301,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"71093015504"},{"Id":416302,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100310","GenericName":"ZOLPIDEM TARTRATE TAB 5 MG","NDC":"71093015506"},{"Id":416303,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"71093015604"},{"Id":416304,"FormularyType":"OHP","DrugName":"ZOLPIDEM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60204080100315","GenericName":"ZOLPIDEM TARTRATE TAB 10 MG","NDC":"71093015606"},{"Id":416305,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"71093016104"},{"Id":416306,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"71093016105"},{"Id":416307,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"71093016204"},{"Id":416308,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"71093016205"},{"Id":416309,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"71093016304"},{"Id":416310,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"71093016305"},{"Id":416311,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM/20ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E530","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 2 GM/20ML","NDC":"71139708701"},{"Id":416312,"FormularyType":"OHP","DrugName":"CEFAZOL/NACL INJ 3/100ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015122030","GenericName":"CEFAZOLIN SODIUM IN SODIUM CHLORIDE 0.9% IV SOLN 3 GM/100ML","NDC":"71139715301"},{"Id":416313,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"71149000097"},{"Id":416314,"FormularyType":"OHP","DrugName":"D3 2000 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"71149000165"},{"Id":416315,"FormularyType":"OHP","DrugName":"D3 5000 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"71149000166"},{"Id":416316,"FormularyType":"OHP","DrugName":"D3 5000 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"71149000241"},{"Id":416317,"FormularyType":"OHP","DrugName":"BRAINSUSTAIN POW KIDS","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"71149000301"},{"Id":416318,"FormularyType":"OHP","DrugName":"D3 5000 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"71149000405"},{"Id":416319,"FormularyType":"OHP","DrugName":"D3 2000 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"71149000434"},{"Id":416320,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"71149000443"},{"Id":416321,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100305","GenericName":"PHENAZOPYRIDINE HCL TAB 100 MG","NDC":"71186000325"},{"Id":416322,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100310","GenericName":"PHENAZOPYRIDINE HCL TAB 200 MG","NDC":"71186000425"},{"Id":416323,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030107220","GenericName":"HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","NDC":"71186000725"},{"Id":416324,"FormularyType":"OHP","DrugName":"HYOSCYAMINE TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100310","GenericName":"HYOSCYAMINE SULFATE TAB 0.125 MG","NDC":"71186000825"},{"Id":416325,"FormularyType":"OHP","DrugName":"HYOSCYAMINE SUB 0.125MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.125","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49101030100710","GenericName":"HYOSCYAMINE SULFATE SL TAB 0.125 MG","NDC":"71186000925"},{"Id":416326,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"71247012601"},{"Id":416327,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"71247012605"},{"Id":416328,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"71247012701"},{"Id":416329,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"71247012705"},{"Id":416330,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"71247013001"},{"Id":416331,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"71247013005"},{"Id":416332,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"71266108001"},{"Id":416333,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"71266108002"},{"Id":416334,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"71266507301"},{"Id":416335,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142056","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/250ML-0.9%","NDC":"71266507501"},{"Id":416336,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"71266508201"},{"Id":416337,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"71266508301"},{"Id":416338,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142056","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/250ML-0.9%","NDC":"71266508501"},{"Id":416339,"FormularyType":"OHP","DrugName":"JOENJA TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99391540600320","GenericName":"LENIOLISIB PHOSPHATE TAB 70 MG","NDC":"71274017060"},{"Id":416340,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"N","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"71283063502"},{"Id":416341,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1G/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"71285606401"},{"Id":416342,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122055","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1.25 GM/250ML-5%","NDC":"71285607301"},{"Id":416343,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"71285607401"},{"Id":416344,"FormularyType":"OHP","DrugName":"VANCOMYC/D5W INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080122060","GenericName":"VANCOMYCIN HCL-DEXTROSE IV SOLN 1.5 GM/250ML-5%","NDC":"71285607501"},{"Id":416345,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"71285607801"},{"Id":416346,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5GM","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"71285617601"},{"Id":416347,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"71288002210"},{"Id":416348,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102110","GenericName":"VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","NDC":"71288002211"},{"Id":416349,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"71288002320"},{"Id":416350,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"71288002321"},{"Id":416351,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"71288002420"},{"Id":416352,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102115","GenericName":"VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","NDC":"71288002421"},{"Id":416353,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"71288002575"},{"Id":416354,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"71288002675"},{"Id":416355,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"71288003120"},{"Id":416356,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"71288003121"},{"Id":416357,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"71288003191"},{"Id":416358,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"71288003192"},{"Id":416359,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"71288003220"},{"Id":416360,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"71288003221"},{"Id":416361,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"71288003291"},{"Id":416362,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"71288003292"},{"Id":416363,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"71288003375"},{"Id":416364,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"71288003391"},{"Id":416365,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"71288020302"},{"Id":416366,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"71288020303"},{"Id":416367,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"71288020304"},{"Id":416368,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"71288020305"},{"Id":416369,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"71288020310"},{"Id":416370,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"71288020311"},{"Id":416371,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030001"},{"Id":416372,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030002"},{"Id":416373,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030110"},{"Id":416374,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030111"},{"Id":416375,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030230"},{"Id":416376,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030391"},{"Id":416377,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"71288030392"},{"Id":416378,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"71288040101"},{"Id":416379,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"71288040102"},{"Id":416380,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288040201"},{"Id":416381,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288040202"},{"Id":416382,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288040210"},{"Id":416383,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288040211"},{"Id":416384,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288040230"},{"Id":416385,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288040231"},{"Id":416386,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288040301"},{"Id":416387,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288040302"},{"Id":416388,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288040310"},{"Id":416389,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288040311"},{"Id":416390,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"71288040401"},{"Id":416391,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"71288040402"},{"Id":416392,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"71288040404"},{"Id":416393,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"71288040405"},{"Id":416394,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"71288040580"},{"Id":416395,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"71288040581"},{"Id":416396,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288040681"},{"Id":416397,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288040682"},{"Id":416398,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 300/3ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101020102050","GenericName":"ENOXAPARIN SODIUM INJ 300 MG/3ML","NDC":"71288042603"},{"Id":416399,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 300/3ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83101020102050","GenericName":"ENOXAPARIN SODIUM INJ 300 MG/3ML","NDC":"71288042691"},{"Id":416400,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"71288043280"},{"Id":416401,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"71288043281"},{"Id":416402,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"71288043291"},{"Id":416403,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"71288043292"},{"Id":416404,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"71288043382"},{"Id":416405,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"71288043383"},{"Id":416406,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"71288043391"},{"Id":416407,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"71288043392"},{"Id":416408,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"71288043484"},{"Id":416409,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"71288043485"},{"Id":416410,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"71288043491"},{"Id":416411,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"71288043492"},{"Id":416412,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"71288043586"},{"Id":416413,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"71288043587"},{"Id":416414,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"71288043591"},{"Id":416415,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"71288043592"},{"Id":416416,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"71288043688"},{"Id":416417,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"71288043689"},{"Id":416418,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"71288043691"},{"Id":416419,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"71288043692"},{"Id":416420,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"71288043791"},{"Id":416421,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"71288043792"},{"Id":416422,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"71288043793"},{"Id":416423,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"71288043794"},{"Id":416424,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"71288043893"},{"Id":416425,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"71288043894"},{"Id":416426,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"71288043895"},{"Id":416427,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"71288043896"},{"Id":416428,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288044901"},{"Id":416429,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"71288044902"},{"Id":416430,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288045001"},{"Id":416431,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"71288045002"},{"Id":416432,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"71288045101"},{"Id":416433,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"71288045102"},{"Id":416434,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"71288056384"},{"Id":416435,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"71288056385"},{"Id":416436,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"71288056701"},{"Id":416437,"FormularyType":"OHP","DrugName":"OCTREOTIDE INJ 100MCG","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"SOMATOSTATIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30170070102010","GenericName":"OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","NDC":"71288056702"},{"Id":416438,"FormularyType":"OHP","DrugName":"LEUPROLIDE INJ 14 DAY","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"71288056990"},{"Id":416439,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 0.4MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E510","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 0.4 MG/ML","NDC":"71288081480"},{"Id":416440,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 0.4MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E510","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 0.4 MG/ML","NDC":"71288081481"},{"Id":416441,"FormularyType":"OHP","DrugName":"YUSIMRY INJ 40/0.8ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001509D520","GenericName":"ADALIMUMAB-AQVH SOLN AUTO-INJECTOR 40 MG/0.8ML","NDC":"71288081580"},{"Id":416442,"FormularyType":"OHP","DrugName":"YUSIMRY INJ 40/0.8ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001509D520","GenericName":"ADALIMUMAB-AQVH SOLN AUTO-INJECTOR 40 MG/0.8ML","NDC":"71288081581"},{"Id":416443,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 100MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007420","GenericName":"THEOPHYLLINE TAB ER 12HR 100 MG","NDC":"71321050010"},{"Id":416444,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 200MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007430","GenericName":"THEOPHYLLINE TAB ER 12HR 200 MG","NDC":"71321050110"},{"Id":416445,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"71321080116"},{"Id":416446,"FormularyType":"OHP","DrugName":"TAVALISSE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATAOLOGIC - TYROSINE KINASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85756040100310","GenericName":"FOSTAMATINIB DISODIUM TAB 100 MG (BASE EQUIVALENT)","NDC":"71332000101"},{"Id":416447,"FormularyType":"OHP","DrugName":"TAVALISSE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"HEMATAOLOGIC - TYROSINE KINASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85756040100320","GenericName":"FOSTAMATINIB DISODIUM TAB 150 MG (BASE EQUIVALENT)","NDC":"71332000201"},{"Id":416448,"FormularyType":"OHP","DrugName":"REZLIDHIA CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21534960000120","GenericName":"OLUTASIDENIB CAP 150 MG","NDC":"71332000501"},{"Id":416449,"FormularyType":"OHP","DrugName":"GAVRETO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535750000120","GenericName":"PRALSETINIB CAP 100 MG","NDC":"71332000660"},{"Id":416450,"FormularyType":"OHP","DrugName":"GAVRETO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535750000120","GenericName":"PRALSETINIB CAP 100 MG","NDC":"71332000690"},{"Id":416451,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85870050700310","GenericName":"MITAPIVAT SULFATE TAB 5 MG","NDC":"71334020505"},{"Id":416452,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85870050700310","GenericName":"MITAPIVAT SULFATE TAB 5 MG","NDC":"71334020514"},{"Id":416453,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85870050700325","GenericName":"MITAPIVAT SULFATE TAB 20 MG","NDC":"71334021014"},{"Id":416454,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85870050700325","GenericName":"MITAPIVAT SULFATE TAB 20 MG","NDC":"71334021020"},{"Id":416455,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85870050700340","GenericName":"MITAPIVAT SULFATE TAB 50 MG","NDC":"71334021514"},{"Id":416456,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85870050700340","GenericName":"MITAPIVAT SULFATE TAB 50 MG","NDC":"71334021550"},{"Id":416457,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 5MG TP","DosageForm":"TBPK - Tab Ther Pack","Strength":"5","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8587005070B710","GenericName":"MITAPIVAT SULFATE TAB THERAPY PACK 5 MG","NDC":"71334022011"},{"Id":416458,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 20MGX5MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8587005070B720","GenericName":"MITAPIVAT SULFATE TAB THERAPY PACK 7 X 20 MG & 7 X 5 MG","NDC":"71334022512"},{"Id":416459,"FormularyType":"OHP","DrugName":"PYRUKYND TAB 50MGX20M","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PYRUVATE KINASE ACTIVATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8587005070B735","GenericName":"MITAPIVAT SULFATE TAB THERAPY PACK 7 X 50 MG & 7 X 20 MG","NDC":"71334023013"},{"Id":416460,"FormularyType":"OHP","DrugName":"PHOSPHOROUS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"PHOSPHATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79600030100320","GenericName":"POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG","NDC":"71351001101"},{"Id":416461,"FormularyType":"OHP","DrugName":"DOPTELET SPR CAP 10MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"10","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405010206820","GenericName":"AVATROMBOPAG MALEATE CAP SPRINKLE 10 MG (BASE EQUIV)","NDC":"71369001030"},{"Id":416462,"FormularyType":"OHP","DrugName":"DOPTELET TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405010200320","GenericName":"AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV)","NDC":"71369002010"},{"Id":416463,"FormularyType":"OHP","DrugName":"DOPTELET TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405010200320","GenericName":"AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV)","NDC":"71369002011"},{"Id":416464,"FormularyType":"OHP","DrugName":"DOPTELET TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405010200320","GenericName":"AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV)","NDC":"71369002015"},{"Id":416465,"FormularyType":"OHP","DrugName":"DOPTELET TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405010200320","GenericName":"AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV)","NDC":"71369002030"},{"Id":416466,"FormularyType":"OHP","DrugName":"MAXRELIEF JR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002004"},{"Id":416467,"FormularyType":"OHP","DrugName":"MAXRELIEF JR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002006"},{"Id":416468,"FormularyType":"OHP","DrugName":"MAXRELIEF JR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002008"},{"Id":416469,"FormularyType":"OHP","DrugName":"MAX RELIEFJR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002104"},{"Id":416470,"FormularyType":"OHP","DrugName":"MAX RELIEFJR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002106"},{"Id":416471,"FormularyType":"OHP","DrugName":"MAX RELIEFJR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002108"},{"Id":416472,"FormularyType":"OHP","DrugName":"MAXRELIEF JR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002204"},{"Id":416473,"FormularyType":"OHP","DrugName":"MAXRELIEF JR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002206"},{"Id":416474,"FormularyType":"OHP","DrugName":"MAXRELIEF JR LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"71399002208"},{"Id":416475,"FormularyType":"OHP","DrugName":"ONELAX SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"71399002708"},{"Id":416476,"FormularyType":"OHP","DrugName":"FERROUS SUL SOL 220/5ML","DosageForm":"SOLN - Solution","Strength":"220","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002030","GenericName":"FERROUS SULFATE SOLN 220 MG/5ML (44 MG/5ML ELEMENTAL FE)","NDC":"71399004006"},{"Id":416477,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"71399005101"},{"Id":416478,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"71399005102"},{"Id":416479,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"71399005301"},{"Id":416480,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"71399005302"},{"Id":416481,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"71399006301"},{"Id":416482,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"71399006305"},{"Id":416483,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"71399006306"},{"Id":416484,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"71399006308"},{"Id":416485,"FormularyType":"OHP","DrugName":"HYDROCORT LOT 1%","DosageForm":"LOTN - Lotion","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004115","GenericName":"HYDROCORTISONE LOTION 1%","NDC":"71399012001"},{"Id":416486,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"71399014004"},{"Id":416487,"FormularyType":"OHP","DrugName":"AMMONIUM LAC LOT 12%","DosageForm":"LOTN - Lotion","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015004130","GenericName":"LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","NDC":"71399014008"},{"Id":416488,"FormularyType":"OHP","DrugName":"MEDPURA HC CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"71399018002"},{"Id":416489,"FormularyType":"OHP","DrugName":"AMMONIUM LAC CRE 12%","DosageForm":"CREA - Cream","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90650015003730","GenericName":"LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","NDC":"71399049404"},{"Id":416490,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"71399101401"},{"Id":416491,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"71399101402"},{"Id":416492,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"71399101701"},{"Id":416493,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"71399101702"},{"Id":416494,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"71399101703"},{"Id":416495,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"71399102501"},{"Id":416496,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"71399102502"},{"Id":416497,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"71399102503"},{"Id":416498,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"71399102506"},{"Id":416499,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"71399102601"},{"Id":416500,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"71399102602"},{"Id":416501,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"71399102701"},{"Id":416502,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"71399102702"},{"Id":416503,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"71399102801"},{"Id":416504,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"71399102802"},{"Id":416505,"FormularyType":"OHP","DrugName":"ONE VITE TAB 1MG PLUS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"71399624609"},{"Id":416506,"FormularyType":"OHP","DrugName":"D-VITE PEDIA DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"71399740105"},{"Id":416507,"FormularyType":"OHP","DrugName":"POLY-VITE SOL IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"71399742005"},{"Id":416508,"FormularyType":"OHP","DrugName":"POLY-VITE SOL 50MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"71399744005"},{"Id":416509,"FormularyType":"OHP","DrugName":"FE-VITE IRON SOL 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"71399748005"},{"Id":416510,"FormularyType":"OHP","DrugName":"TRI-VITE DRO PEDIATRI","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002006","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 750 UNIT-400 UNIT-35 MG/ML***","NDC":"71399750405"},{"Id":416511,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 2.5MG","DosageForm":"LIQD - Liquid","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000920","GenericName":"MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML)","NDC":"71399783708"},{"Id":416512,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"71399804201"},{"Id":416513,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"71399804203"},{"Id":416514,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"71399824501"},{"Id":416515,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"71399824503"},{"Id":416516,"FormularyType":"OHP","DrugName":"UREA 20 INTN CRE 20%","DosageForm":"CREA - Cream","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003715","GenericName":"UREA CREAM 20%","NDC":"71399843403"},{"Id":416517,"FormularyType":"OHP","DrugName":"UREA LOT 40%","DosageForm":"LOTN - Lotion","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080004140","GenericName":"UREA LOTION 40%","NDC":"71399845508"},{"Id":416518,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"71399845601"},{"Id":416519,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"71399845603"},{"Id":416520,"FormularyType":"OHP","DrugName":"UREA CRE 40%","DosageForm":"CREA - Cream","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003725","GenericName":"UREA CREAM 40%","NDC":"71399845607"},{"Id":416521,"FormularyType":"OHP","DrugName":"ONELAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"71399846002"},{"Id":416522,"FormularyType":"OHP","DrugName":"ONELAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"71399846005"},{"Id":416523,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"71399865901"},{"Id":416524,"FormularyType":"OHP","DrugName":"CALCIUM CARB CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"71399993901"},{"Id":416525,"FormularyType":"OHP","DrugName":"CALCIUM CARB CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"71399994001"},{"Id":416526,"FormularyType":"OHP","DrugName":"ONEVITE TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"71399994201"},{"Id":416527,"FormularyType":"OHP","DrugName":"ONEVITE TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"71399994202"},{"Id":416528,"FormularyType":"OHP","DrugName":"ONEVITE TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"71399994203"},{"Id":416529,"FormularyType":"OHP","DrugName":"ONEVITE TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"71399994205"},{"Id":416530,"FormularyType":"OHP","DrugName":"ONEVITE TAB 500-5MCG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"71399994206"},{"Id":416531,"FormularyType":"OHP","DrugName":"ONEVITE TAB 600-5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"71399996801"},{"Id":416532,"FormularyType":"OHP","DrugName":"ONEVITE TAB 600-5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"71399996803"},{"Id":416533,"FormularyType":"OHP","DrugName":"OMEGA 3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"71410010001"},{"Id":416534,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 750/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142028","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 750 MG/250ML-0.9%","NDC":"71506001458"},{"Id":416535,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"71506001558"},{"Id":416536,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"71506001659"},{"Id":416537,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.75/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142076","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.75 GM/500ML-0.9%","NDC":"71506001759"},{"Id":416538,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"71506001858"},{"Id":416539,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"71506001959"},{"Id":416540,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"71506003758"},{"Id":416541,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"71550010090"},{"Id":416542,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"71550010101"},{"Id":416543,"FormularyType":"OHP","DrugName":"BRINSUPRI TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"RESPIRATORY AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45001508000310","GenericName":"BRENSOCATIB TAB 10 MG","NDC":"71558000130"},{"Id":416544,"FormularyType":"OHP","DrugName":"BRINSUPRI TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"RESPIRATORY AGENTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45001508000320","GenericName":"BRENSOCATIB TAB 25 MG","NDC":"71558000230"},{"Id":416545,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000320","GenericName":"ZOLMITRIPTAN TAB 2.5 MG","NDC":"71626010106"},{"Id":416546,"FormularyType":"OHP","DrugName":"ZOLMITRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406080000330","GenericName":"ZOLMITRIPTAN TAB 5 MG","NDC":"71626010203"},{"Id":416547,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"71626020101"},{"Id":416548,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"71626030201"},{"Id":416549,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"71626030205"},{"Id":416550,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"71626030230"},{"Id":416551,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"71626030301"},{"Id":416552,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"71626030305"},{"Id":416553,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"71626030330"},{"Id":416554,"FormularyType":"OHP","DrugName":"LEVOCARNITIN SOL 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045102010","GenericName":"LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)","NDC":"71656001650"},{"Id":416555,"FormularyType":"OHP","DrugName":"LEVOCARNITIN SOL 1GM/10ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30903045102010","GenericName":"LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)","NDC":"71656001651"},{"Id":416556,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"71656002101"},{"Id":416557,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"71656002116"},{"Id":416558,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"71656002150"},{"Id":416559,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"71656002151"},{"Id":416560,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"71656002216"},{"Id":416561,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"71656002250"},{"Id":416562,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN SOL 2%","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051020002010","GenericName":"ERYTHROMYCIN SOLN 2%","NDC":"71656003060"},{"Id":416563,"FormularyType":"OHP","DrugName":"TRIAMCINOLON LOT 0.1%","DosageForm":"LOTN - Lotion","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085104110","GenericName":"TRIAMCINOLONE ACETONIDE LOTION 0.1%","NDC":"71656004060"},{"Id":416564,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"71656004215"},{"Id":416565,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"71656004230"},{"Id":416566,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"71656004280"},{"Id":416567,"FormularyType":"OHP","DrugName":"HC/ACET ACID SOL 1-2%OTIC","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87300020102000","GenericName":"HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%","NDC":"71656006410"},{"Id":416568,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"71656006770"},{"Id":416569,"FormularyType":"OHP","DrugName":"ACAM2000 INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100085002150","GenericName":"*SMALLPOX VACCINE FOR PERCUTANEOUS INJ**","NDC":"71665033001"},{"Id":416570,"FormularyType":"OHP","DrugName":"ACAM2000 INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100085002150","GenericName":"*SMALLPOX VACCINE FOR PERCUTANEOUS INJ**","NDC":"71665033002"},{"Id":416571,"FormularyType":"OHP","DrugName":"ACAM2000 INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100085002150","GenericName":"*SMALLPOX VACCINE FOR PERCUTANEOUS INJ**","NDC":"71665043001"},{"Id":416572,"FormularyType":"OHP","DrugName":"ACAM2000 INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100085002150","GenericName":"*SMALLPOX VACCINE FOR PERCUTANEOUS INJ**","NDC":"71665043002"},{"Id":416573,"FormularyType":"OHP","DrugName":"ACAM2000 INJ","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"17100085002150","GenericName":"*SMALLPOX VACCINE FOR PERCUTANEOUS INJ**","NDC":"71665043003"},{"Id":416574,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"71709011006"},{"Id":416575,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"71709011007"},{"Id":416576,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"71709011106"},{"Id":416577,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"71709011107"},{"Id":416578,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"71709011206"},{"Id":416579,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"71709011207"},{"Id":416580,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"71709012904"},{"Id":416581,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"71709012906"},{"Id":416582,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"71709013004"},{"Id":416583,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"71709013006"},{"Id":416584,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"71717010103"},{"Id":416585,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"71717010109"},{"Id":416586,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"71717010150"},{"Id":416587,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"71717010210"},{"Id":416588,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"71717010250"},{"Id":416589,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"71717010310"},{"Id":416590,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"71717010350"},{"Id":416591,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"71717010411"},{"Id":416592,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"71717010510"},{"Id":416593,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"71717010550"},{"Id":416594,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"71717010611"},{"Id":416595,"FormularyType":"OHP","DrugName":"SSKI SOL 1GM/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"EXPECTORANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43202010002060","GenericName":"POTASSIUM IODIDE ORAL SOLN 1 GM/ML","NDC":"71740011230"},{"Id":416596,"FormularyType":"OHP","DrugName":"VITRAKVI SOL 20MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533835202020","GenericName":"LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT)","NDC":"71777039201"},{"Id":416597,"FormularyType":"OHP","DrugName":"AVMAPKI PAK FAKZYNJA","DosageForm":"THPK - Therapy Pack","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2199000207B120","GenericName":"AVUTOMETINIB CAP 0.8 MG & DEFACTINIB TAB 200 MG THERAPY PACK","NDC":"71779062301"},{"Id":416598,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"71800001301"},{"Id":416599,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"71800001501"},{"Id":416600,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"71800001901"},{"Id":416601,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"71800005819"},{"Id":416602,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"71839010910"},{"Id":416603,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"71839011010"},{"Id":416604,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"71839011110"},{"Id":416605,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"71839011210"},{"Id":416606,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"71839011310"},{"Id":416607,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"71839011510"},{"Id":416608,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"71839011610"},{"Id":416609,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/0.5","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202034","GenericName":"HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","NDC":"71839011825"},{"Id":416610,"FormularyType":"OHP","DrugName":"TRYNGOLZA INJ 80MG/0.8","DosageForm":"SOAJ - Soln Auto-inj","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3090626530D540","GenericName":"OLEZARSEN SOD SUBCUT SOLN AUTO-INJECT 80 MG/0.8ML (BASE EQ)","NDC":"71860010101"},{"Id":416611,"FormularyType":"OHP","DrugName":"DAWNZERA INJ 80/0.8ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"80","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PREKALLIKREIN-DIRECTED ANTISENSE OLIGONUCLEOTIDES (ASO)","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8547002070D520","GenericName":"DONIDALORSEN SODIUM SUBCUTANEOUS SOLN AUTO-INJ 80 MG/0.8ML","NDC":"71860010301"},{"Id":416612,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"71862000301"},{"Id":416613,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"71862000701"},{"Id":416614,"FormularyType":"OHP","DrugName":"INCRELEX INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30160045002020","GenericName":"MECASERMIN INJ 40 MG/4ML (10 MG/ML)","NDC":"71863021604"},{"Id":416615,"FormularyType":"OHP","DrugName":"TENOFOVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12108570100320","GenericName":"TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","NDC":"71921010533"},{"Id":416616,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"71921014601"},{"Id":416617,"FormularyType":"OHP","DrugName":"SUMATRIPTAN SPR 20MG/ACT","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406070002040","GenericName":"SUMATRIPTAN NASAL SPRAY 20 MG/ACT","NDC":"71921017061"},{"Id":416618,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"71921017706"},{"Id":416619,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"71921017820"},{"Id":416620,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"71921018001"},{"Id":416621,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"71921018050"},{"Id":416622,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"71921018101"},{"Id":416623,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"71921018150"},{"Id":416624,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"71921018201"},{"Id":416625,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"71921018250"},{"Id":416626,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"71921018505"},{"Id":416627,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"71921018510"},{"Id":416628,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.2% OP","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102010","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","NDC":"71921018515"},{"Id":416629,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"71921019033"},{"Id":416630,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"71921021012"},{"Id":416631,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"71921021401"},{"Id":416632,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000310","GenericName":"GLIMEPIRIDE TAB 1 MG","NDC":"71921021450"},{"Id":416633,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"71921021501"},{"Id":416634,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000320","GenericName":"GLIMEPIRIDE TAB 2 MG","NDC":"71921021550"},{"Id":416635,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"71921021601"},{"Id":416636,"FormularyType":"OHP","DrugName":"GLIMEPIRIDE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200027000340","GenericName":"GLIMEPIRIDE TAB 4 MG","NDC":"71921021650"},{"Id":416637,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000320","GenericName":"LACOSAMIDE TAB 50 MG","NDC":"71921022006"},{"Id":416638,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000330","GenericName":"LACOSAMIDE TAB 100 MG","NDC":"71921022106"},{"Id":416639,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000340","GenericName":"LACOSAMIDE TAB 150 MG","NDC":"71921022206"},{"Id":416640,"FormularyType":"OHP","DrugName":"LACOSAMIDE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036000350","GenericName":"LACOSAMIDE TAB 200 MG","NDC":"71921022306"},{"Id":416641,"FormularyType":"OHP","DrugName":"DORZOL/TIMOL SOL 2-0.5%OP","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86259902202020","GenericName":"DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 2-0.5%","NDC":"71921022610"},{"Id":416642,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"71921024001"},{"Id":416643,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"71921024050"},{"Id":416644,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"71921024060"},{"Id":416645,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000307","GenericName":"ALLOPURINOL TAB 200 MG","NDC":"71921024109"},{"Id":416646,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"71921024201"},{"Id":416647,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"71921024250"},{"Id":416648,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"71921024260"},{"Id":416649,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"71921030751"},{"Id":416650,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"71921030856"},{"Id":416651,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"71921030956"},{"Id":416652,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"71921040010"},{"Id":416653,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"71921041171"},{"Id":416654,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"71930000612"},{"Id":416655,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"71930000613"},{"Id":416656,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"71930000712"},{"Id":416657,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"71930000713"},{"Id":416658,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"71930000812"},{"Id":416659,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"71930000912"},{"Id":416660,"FormularyType":"OHP","DrugName":"QUINIDINE GL TAB 324MG ER","DosageForm":"TBCR - Tablet ER","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100030100403","GenericName":"QUINIDINE GLUCONATE TAB ER 324 MG","NDC":"71930001612"},{"Id":416661,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"71930001912"},{"Id":416662,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"71930001913"},{"Id":416663,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"71930001952"},{"Id":416664,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"71930002012"},{"Id":416665,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"71930002013"},{"Id":416666,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"71930002052"},{"Id":416667,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"71930002112"},{"Id":416668,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"71930002113"},{"Id":416669,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"71930002152"},{"Id":416670,"FormularyType":"OHP","DrugName":"OXYCODONE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075102005","GenericName":"OXYCODONE HCL SOLN 5 MG/5ML","NDC":"71930002243"},{"Id":416671,"FormularyType":"OHP","DrugName":"OXYCODONE CON 100/5ML","DosageForm":"CONC - Concentrate","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075101320","GenericName":"OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML)","NDC":"71930002330"},{"Id":416672,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102020","GenericName":"METHYLPHENIDATE HCL SOLN 5 MG/5ML","NDC":"71930002452"},{"Id":416673,"FormularyType":"OHP","DrugName":"METHYLPHENID SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"61400020102030","GenericName":"METHYLPHENIDATE HCL SOLN 10 MG/5ML","NDC":"71930002552"},{"Id":416674,"FormularyType":"OHP","DrugName":"HYDROCO/APAP SOL 7.5-325","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702102015","GenericName":"HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","NDC":"71930002743"},{"Id":416675,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"71930004512"},{"Id":416676,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"71930004552"},{"Id":416677,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"71930004612"},{"Id":416678,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"71930004652"},{"Id":416679,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"71930004712"},{"Id":416680,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200335","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","NDC":"71930004752"},{"Id":416681,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"71930004812"},{"Id":416682,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"1080","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"71930004912"},{"Id":416683,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"1620","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"71930005012"},{"Id":416684,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050310","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","NDC":"71930005412"},{"Id":416685,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"71930005512"},{"Id":416686,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050315","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","NDC":"71930005552"},{"Id":416687,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"71930005612"},{"Id":416688,"FormularyType":"OHP","DrugName":"APAP/CODEINE TAB 300-60MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991002050320","GenericName":"ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","NDC":"71930005652"},{"Id":416689,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"71930006612"},{"Id":416690,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000303","GenericName":"HYDROCORTISONE TAB 5 MG","NDC":"71930007850"},{"Id":416691,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000305","GenericName":"HYDROCORTISONE TAB 10 MG","NDC":"71930007912"},{"Id":416692,"FormularyType":"OHP","DrugName":"HYDROCORT TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100025000310","GenericName":"HYDROCORTISONE TAB 20 MG","NDC":"71930008012"},{"Id":416693,"FormularyType":"OHP","DrugName":"AYVAKIT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21490009000320","GenericName":"AVAPRITINIB TAB 100 MG","NDC":"72064011030"},{"Id":416694,"FormularyType":"OHP","DrugName":"AYVAKIT TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21490009000330","GenericName":"AVAPRITINIB TAB 200 MG","NDC":"72064012030"},{"Id":416695,"FormularyType":"OHP","DrugName":"AYVAKIT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21490009000310","GenericName":"AVAPRITINIB TAB 25 MG","NDC":"72064012530"},{"Id":416696,"FormularyType":"OHP","DrugName":"AYVAKIT TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21490009000340","GenericName":"AVAPRITINIB TAB 300 MG","NDC":"72064013030"},{"Id":416697,"FormularyType":"OHP","DrugName":"AYVAKIT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21490009000315","GenericName":"AVAPRITINIB TAB 50 MG","NDC":"72064015030"},{"Id":416698,"FormularyType":"OHP","DrugName":"GVOKE HYPO 1 INJ 0.5/.1ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2730001000D520","GenericName":"GLUCAGON SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML","NDC":"72065012011"},{"Id":416699,"FormularyType":"OHP","DrugName":"GVOKE HYPO 2 INJ 0.5/.1ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2730001000D520","GenericName":"GLUCAGON SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML","NDC":"72065012012"},{"Id":416700,"FormularyType":"OHP","DrugName":"GVOKE HYPO 1 INJ 1/0.2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2730001000D530","GenericName":"GLUCAGON SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1 MG/0.2ML","NDC":"72065012111"},{"Id":416701,"FormularyType":"OHP","DrugName":"GVOKE HYPO 2 INJ 1/0.2ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2730001000D530","GenericName":"GLUCAGON SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1 MG/0.2ML","NDC":"72065012112"},{"Id":416702,"FormularyType":"OHP","DrugName":"GVOKE PFS INJ 1/0.2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2730001000E530","GenericName":"GLUCAGON SUBCUTANEOUS SOLN PREF SYRINGE 1 MG/0.2ML","NDC":"72065013111"},{"Id":416703,"FormularyType":"OHP","DrugName":"GVOKE PFS INJ 1/0.2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2730001000E530","GenericName":"GLUCAGON SUBCUTANEOUS SOLN PREF SYRINGE 1 MG/0.2ML","NDC":"72065013112"},{"Id":416704,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"72078003300"},{"Id":416705,"FormularyType":"OHP","DrugName":"ADENOSINE INJ 6MG/2ML","DosageForm":"SOLN - Solution","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35500010002015","GenericName":"ADENOSINE IV SOLN 6 MG/2ML","NDC":"72078003302"},{"Id":416706,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 450MG/9M","DosageForm":"SOLN - Solution","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002040","GenericName":"AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","NDC":"72078004609"},{"Id":416707,"FormularyType":"OHP","DrugName":"AMIODARONE INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"900","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005002050","GenericName":"AMIODARONE HCL INJ 900 MG/18ML (50 MG/ML)","NDC":"72078004618"},{"Id":416708,"FormularyType":"OHP","DrugName":"AQUAPHOR OIN ITCH RLF","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"72140003101"},{"Id":416709,"FormularyType":"OHP","DrugName":"AQUAPHOR OIN ITCH RLF","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"72140003111"},{"Id":416710,"FormularyType":"OHP","DrugName":"AQUAPHOR OIN ITCH RLF","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"72140003270"},{"Id":416711,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"72143025110"},{"Id":416712,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000110","GenericName":"ISOTRETINOIN CAP 10 MG","NDC":"72143025130"},{"Id":416713,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"72143025210"},{"Id":416714,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000120","GenericName":"ISOTRETINOIN CAP 20 MG","NDC":"72143025230"},{"Id":416715,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"72143025310"},{"Id":416716,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000130","GenericName":"ISOTRETINOIN CAP 30 MG","NDC":"72143025330"},{"Id":416717,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"72143025410"},{"Id":416718,"FormularyType":"OHP","DrugName":"ACCUTANE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050013000140","GenericName":"ISOTRETINOIN CAP 40 MG","NDC":"72143025430"},{"Id":416719,"FormularyType":"OHP","DrugName":"ORSERDU TAB 86MG","DosageForm":"TABS - Tablet","Strength":"86","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21403720100320","GenericName":"ELACESTRANT HYDROCHLORIDE TAB 86 MG","NDC":"72187010103"},{"Id":416720,"FormularyType":"OHP","DrugName":"ORSERDU TAB 345MG","DosageForm":"TABS - Tablet","Strength":"345","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21403720100340","GenericName":"ELACESTRANT HYDROCHLORIDE TAB 345 MG","NDC":"72187010203"},{"Id":416721,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1/250ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142040","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1 GM/250ML-0.9%","NDC":"72196606401"},{"Id":416722,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.25/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142048","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.25 GM/250ML-0.9%","NDC":"72196607401"},{"Id":416723,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/250","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142056","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/250ML-0.9%","NDC":"72196607601"},{"Id":416724,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 2/500ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142084","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 2 GM/500ML-0.9%","NDC":"72196607801"},{"Id":416725,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.5/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142064","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.5 GM/500ML-0.9%","NDC":"72196617601"},{"Id":416726,"FormularyType":"OHP","DrugName":"VANCOMY/NACL INJ 1.75/500","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080142076","GenericName":"VANCOMYCIN HCL-SODIUM CHLORIDE IV SOLN 1.75 GM/500ML-0.9%","NDC":"72196706001"},{"Id":416727,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"72205000105"},{"Id":416728,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"72205000130"},{"Id":416729,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"72205000390"},{"Id":416730,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"72205000399"},{"Id":416731,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"72205000490"},{"Id":416732,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"72205000499"},{"Id":416733,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72205000530"},{"Id":416734,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72205000590"},{"Id":416735,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72205000599"},{"Id":416736,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"72205000660"},{"Id":416737,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"72205000792"},{"Id":416738,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"72205001190"},{"Id":416739,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"72205001290"},{"Id":416740,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"72205001390"},{"Id":416741,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"72205001490"},{"Id":416742,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"72205001590"},{"Id":416743,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"72205001690"},{"Id":416744,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"72205001790"},{"Id":416745,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"72205001890"},{"Id":416746,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"72205001901"},{"Id":416747,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"72205002030"},{"Id":416748,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200320","GenericName":"SOLIFENACIN SUCCINATE TAB 5 MG","NDC":"72205002090"},{"Id":416749,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"72205002130"},{"Id":416750,"FormularyType":"OHP","DrugName":"SOLIFENACIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100055200330","GenericName":"SOLIFENACIN SUCCINATE TAB 10 MG","NDC":"72205002190"},{"Id":416751,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72205002205"},{"Id":416752,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72205002290"},{"Id":416753,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72205002299"},{"Id":416754,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72205002305"},{"Id":416755,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72205002390"},{"Id":416756,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72205002399"},{"Id":416757,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72205002405"},{"Id":416758,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72205002490"},{"Id":416759,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72205002499"},{"Id":416760,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72205002505"},{"Id":416761,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72205002590"},{"Id":416762,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72205002599"},{"Id":416763,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"72205002790"},{"Id":416764,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"72205002799"},{"Id":416765,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"72205002830"},{"Id":416766,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"72205002930"},{"Id":416767,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"72205003092"},{"Id":416768,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"72205003474"},{"Id":416769,"FormularyType":"OHP","DrugName":"LEVETIRACETA SOL 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043002020","GenericName":"LEVETIRACETAM ORAL SOLN 100 MG/ML","NDC":"72205003772"},{"Id":416770,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"72205003960"},{"Id":416771,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"72205004060"},{"Id":416772,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"72205004160"},{"Id":416773,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"72205004211"},{"Id":416774,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"72205004311"},{"Id":416775,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"72205004411"},{"Id":416776,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000310","GenericName":"CLOBAZAM TAB 10 MG","NDC":"72205004791"},{"Id":416777,"FormularyType":"OHP","DrugName":"CLOBAZAM TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72100007000320","GenericName":"CLOBAZAM TAB 20 MG","NDC":"72205004891"},{"Id":416778,"FormularyType":"OHP","DrugName":"TOREMIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402685100320","GenericName":"TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT)","NDC":"72205005030"},{"Id":416779,"FormularyType":"OHP","DrugName":"ALBENDAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000002000320","GenericName":"ALBENDAZOLE TAB 200 MG","NDC":"72205005108"},{"Id":416780,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"72205006078"},{"Id":416781,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"72205008030"},{"Id":416782,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"72205008130"},{"Id":416783,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"72205008230"},{"Id":416784,"FormularyType":"OHP","DrugName":"TIAGABINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170070100302","GenericName":"TIAGABINE HCL TAB 2 MG","NDC":"72205008430"},{"Id":416785,"FormularyType":"OHP","DrugName":"TIAGABINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170070100305","GenericName":"TIAGABINE HCL TAB 4 MG","NDC":"72205008530"},{"Id":416786,"FormularyType":"OHP","DrugName":"TIAGABINE TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170070100315","GenericName":"TIAGABINE HCL TAB 12 MG","NDC":"72205008630"},{"Id":416787,"FormularyType":"OHP","DrugName":"TIAGABINE TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"N","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"GABA MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72170070100320","GenericName":"TIAGABINE HCL TAB 16 MG","NDC":"72205008730"},{"Id":416788,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"72205009492"},{"Id":416789,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"72205009592"},{"Id":416790,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"72205009692"},{"Id":416791,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"72205009760"},{"Id":416792,"FormularyType":"OHP","DrugName":"PYRIDOSTIGMI SOL 60MG/5ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","DrugSubClass":"ANTIMYASTHENIC/CHOLINERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"76000050102060","GenericName":"PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","NDC":"72205009872"},{"Id":416793,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"72205009978"},{"Id":416794,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72205010101"},{"Id":416795,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72205010107"},{"Id":416796,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72205010201"},{"Id":416797,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72205010207"},{"Id":416798,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"72205011628"},{"Id":416799,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"72205011728"},{"Id":416800,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"72205011828"},{"Id":416801,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"72205011928"},{"Id":416802,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000320","GenericName":"TOLVAPTAN TAB 15 MG","NDC":"72205013011"},{"Id":416803,"FormularyType":"OHP","DrugName":"TOLVAPTAN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"VASOPRESSIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30454060000330","GenericName":"TOLVAPTAN TAB 30 MG","NDC":"72205013111"},{"Id":416804,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72205014190"},{"Id":416805,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72205014199"},{"Id":416806,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72205014230"},{"Id":416807,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72205014290"},{"Id":416808,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72205014299"},{"Id":416809,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72205014330"},{"Id":416810,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72205014390"},{"Id":416811,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72205014399"},{"Id":416812,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72205014505"},{"Id":416813,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72205014530"},{"Id":416814,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72205014591"},{"Id":416815,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72205014599"},{"Id":416816,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72205014605"},{"Id":416817,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72205014630"},{"Id":416818,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72205014691"},{"Id":416819,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72205014699"},{"Id":416820,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100310","GenericName":"ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","NDC":"72205015630"},{"Id":416821,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100320","GenericName":"ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","NDC":"72205015730"},{"Id":416822,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100330","GenericName":"ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","NDC":"72205015830"},{"Id":416823,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100340","GenericName":"ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","NDC":"72205015930"},{"Id":416824,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"72205016530"},{"Id":416825,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"72205016590"},{"Id":416826,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"72205016630"},{"Id":416827,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"72205016666"},{"Id":416828,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"72205016690"},{"Id":416829,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"72205016730"},{"Id":416830,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"72205016766"},{"Id":416831,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"72205016790"},{"Id":416832,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"72205016860"},{"Id":416833,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"72205017072"},{"Id":416834,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"72205018126"},{"Id":416835,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"72205018136"},{"Id":416836,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"72205018190"},{"Id":416837,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"72205018290"},{"Id":416838,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"72205018460"},{"Id":416839,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"72205018530"},{"Id":416840,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"72205019901"},{"Id":416841,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"72205019905"},{"Id":416842,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"72205019930"},{"Id":416843,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"72205019990"},{"Id":416844,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"72205020030"},{"Id":416845,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000320","GenericName":"ROFLUMILAST TAB 500 MCG","NDC":"72205020090"},{"Id":416846,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"72205020111"},{"Id":416847,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"72205020113"},{"Id":416848,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"72205020124"},{"Id":416849,"FormularyType":"OHP","DrugName":"ROFLUMILAST TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44450065000310","GenericName":"ROFLUMILAST TAB 250 MCG","NDC":"72205020132"},{"Id":416850,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"72205020260"},{"Id":416851,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200130","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","NDC":"72205020360"},{"Id":416852,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"72205020460"},{"Id":416853,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72205022001"},{"Id":416854,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72205022007"},{"Id":416855,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"72205023384"},{"Id":416856,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"72205023964"},{"Id":416857,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"72205027590"},{"Id":416858,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"72205027591"},{"Id":416859,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"72205027599"},{"Id":416860,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"72205027691"},{"Id":416861,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"72205027699"},{"Id":416862,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"72205027791"},{"Id":416863,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"72205027795"},{"Id":416864,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"72205028018"},{"Id":416865,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"72205028060"},{"Id":416866,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"72205028118"},{"Id":416867,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"72205028160"},{"Id":416868,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"72205028218"},{"Id":416869,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"72205028260"},{"Id":416870,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"72205028492"},{"Id":416871,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"72205028560"},{"Id":416872,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100320","GenericName":"IVABRADINE HCL TAB 5 MG (BASE EQUIV)","NDC":"72205033660"},{"Id":416873,"FormularyType":"OHP","DrugName":"IVABRADINE TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"SINUS NODE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40700035100330","GenericName":"IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","NDC":"72205033760"},{"Id":416874,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"72217000101"},{"Id":416875,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"72217000601"},{"Id":416876,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"72217000602"},{"Id":416877,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"72217000603"},{"Id":416878,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"72217000604"},{"Id":416879,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"72217000605"},{"Id":416880,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"72217000606"},{"Id":416881,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"72217000607"},{"Id":416882,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"72217000701"},{"Id":416883,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"72217000702"},{"Id":416884,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"72217000703"},{"Id":416885,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"72217000704"},{"Id":416886,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"72217000705"},{"Id":416887,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"72217000706"},{"Id":416888,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"72217000707"},{"Id":416889,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"72217000708"},{"Id":416890,"FormularyType":"OHP","DrugName":"PROCARE MIS ADULT","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"72217003901"},{"Id":416891,"FormularyType":"OHP","DrugName":"PROCARE MIS CHILD","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"72217003902"},{"Id":416892,"FormularyType":"OHP","DrugName":"XPOVIO PAK 60MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - XPO1 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2156006000B755","GenericName":"SELINEXOR TAB THERAPY PACK 20 MG (60 MG TWICE WEEKLY)","NDC":"72237010103"},{"Id":416893,"FormularyType":"OHP","DrugName":"XPOVIO PAK 80MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - XPO1 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2156006000B720","GenericName":"SELINEXOR TAB THERAPY PACK 20 MG (80 MG TWICE WEEKLY)","NDC":"72237010104"},{"Id":416894,"FormularyType":"OHP","DrugName":"XPOVIO PAK 60MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - XPO1 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2156006000B755","GenericName":"SELINEXOR TAB THERAPY PACK 20 MG (60 MG TWICE WEEKLY)","NDC":"72237010113"},{"Id":416895,"FormularyType":"OHP","DrugName":"XPOVIO PAK 80MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - XPO1 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2156006000B720","GenericName":"SELINEXOR TAB THERAPY PACK 20 MG (80 MG TWICE WEEKLY)","NDC":"72237010114"},{"Id":416896,"FormularyType":"OHP","DrugName":"XPOVIO PAK 80MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - XPO1 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2156006000B785","GenericName":"SELINEXOR TAB THERAPY PACK 80 MG (80 MG ONCE WEEKLY)","NDC":"72237010501"},{"Id":416897,"FormularyType":"OHP","DrugName":"XPOVIO PAK 80MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - XPO1 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2156006000B785","GenericName":"SELINEXOR TAB THERAPY PACK 80 MG (80 MG ONCE WEEKLY)","NDC":"72237010511"},{"Id":416898,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"72241000204"},{"Id":416899,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"72241000205"},{"Id":416900,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"72241000304"},{"Id":416901,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"72241000305"},{"Id":416902,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"72241000411"},{"Id":416903,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"72241000511"},{"Id":416904,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"72241000605"},{"Id":416905,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"72241001005"},{"Id":416906,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"72241001011"},{"Id":416907,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"72241001022"},{"Id":416908,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"72241001103"},{"Id":416909,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"72241001203"},{"Id":416910,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"72241001303"},{"Id":416911,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"72241001403"},{"Id":416912,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"72241001522"},{"Id":416913,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"72241001622"},{"Id":416914,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"72241001722"},{"Id":416915,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"72241002305"},{"Id":416916,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"72241002310"},{"Id":416917,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"72241002405"},{"Id":416918,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"72241002410"},{"Id":416919,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"72241002805"},{"Id":416920,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 1.25MG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000305","GenericName":"GLYBURIDE TAB 1.25 MG","NDC":"72241003805"},{"Id":416921,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"72241003905"},{"Id":416922,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"72241003910"},{"Id":416923,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000310","GenericName":"GLYBURIDE TAB 2.5 MG","NDC":"72241003911"},{"Id":416924,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"72241004005"},{"Id":416925,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"72241004010"},{"Id":416926,"FormularyType":"OHP","DrugName":"GLYBURIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200040000315","GenericName":"GLYBURIDE TAB 5 MG","NDC":"72241004011"},{"Id":416927,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"72241005005"},{"Id":416928,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"72241005011"},{"Id":416929,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"72266013901"},{"Id":416930,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"72266014001"},{"Id":416931,"FormularyType":"OHP","DrugName":"AZELASTINE DRO 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802006102020","GenericName":"AZELASTINE HCL OPHTH SOLN 0.05%","NDC":"72266014101"},{"Id":416932,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN SOL 0.5%","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101038102020","GenericName":"MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","NDC":"72266015801"},{"Id":416933,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"72266015905"},{"Id":416934,"FormularyType":"OHP","DrugName":"ERTAPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150030102130","GenericName":"ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","NDC":"72266015910"},{"Id":416935,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"72266019701"},{"Id":416936,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"72266019901"},{"Id":416937,"FormularyType":"OHP","DrugName":"BIMATOPROST SOL 0.03% OP","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"PROSTAGLANDINS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86330015002020","GenericName":"BIMATOPROST OPHTH SOLN 0.03%","NDC":"72266024101"},{"Id":416938,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72266024201"},{"Id":416939,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200MG/20","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72266024205"},{"Id":416940,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN INJ 100MCG","DosageForm":"SOLR - Solution Reconstituted","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010102103","GenericName":"LEVOTHYROXINE SODIUM FOR IV INJ 100 MCG","NDC":"72266026101"},{"Id":416941,"FormularyType":"OHP","DrugName":"JENLIVA CAP","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000115","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/ IRON & FA CAP 1 MG***","NDC":"72275030130"},{"Id":416942,"FormularyType":"OHP","DrugName":"SELEGILINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100320","GenericName":"SELEGILINE HCL TAB 5 MG","NDC":"72319000602"},{"Id":416943,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"72319001804"},{"Id":416944,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"72319001904"},{"Id":416945,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"72319002102"},{"Id":416946,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"72319002202"},{"Id":416947,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"72319002302"},{"Id":416948,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000320","GenericName":"MARAVIROC TAB 150 MG","NDC":"72319002402"},{"Id":416949,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000330","GenericName":"MARAVIROC TAB 300 MG","NDC":"72319002502"},{"Id":416950,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 16MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"16","BrandVsGeneric":"N","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007260","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 16 MG","NDC":"72336007330"},{"Id":416951,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000335","GenericName":"METFORMIN HCL TAB 750 MG","NDC":"72336009530"},{"Id":416952,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"72336022560"},{"Id":416953,"FormularyType":"OHP","DrugName":"SUSPENDRX SUS UNSWEET","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"72467010080"},{"Id":416954,"FormularyType":"OHP","DrugName":"SUSPENDRX SUS UNSWEET","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"72467010085"},{"Id":416955,"FormularyType":"OHP","DrugName":"SUSPENDRX SUS SWEET","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"72467010480"},{"Id":416956,"FormularyType":"OHP","DrugName":"SUSPENDRX SUS SWEET","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000001800","GenericName":"*ORAL VEHICLES - SUSP***","NDC":"72467010485"},{"Id":416957,"FormularyType":"OHP","DrugName":"ORAPENN SD LIQ SWEET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"72467022780"},{"Id":416958,"FormularyType":"OHP","DrugName":"ORAPENN SD LIQ SWEET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"72467022785"},{"Id":416959,"FormularyType":"OHP","DrugName":"ORAPENN SD LIQ SWEET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"72467022795"},{"Id":416960,"FormularyType":"OHP","DrugName":"ORAPENN SD LIQ UNSWEET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98402000000900","GenericName":"*ORAL VEHICLES***","NDC":"72467022895"},{"Id":416961,"FormularyType":"OHP","DrugName":"VONJO CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537550100120","GenericName":"PACRITINIB CITRATE CAP 100 MG","NDC":"72482010012"},{"Id":416962,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"72485010105"},{"Id":416963,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"72485010125"},{"Id":416964,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"72485010401"},{"Id":416965,"FormularyType":"OHP","DrugName":"CAFFEINE CIT INJ 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102020","GenericName":"CAFFEINE CITRATE INJ 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"72485010410"},{"Id":416966,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"72485010805"},{"Id":416967,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 5MG/2ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"72485010825"},{"Id":416968,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"72485010901"},{"Id":416969,"FormularyType":"OHP","DrugName":"VERAPAMIL INJ 10MG/4ML","DosageForm":"SOLN - Solution","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030102005","GenericName":"VERAPAMIL HCL IV SOLN 2.5 MG/ML","NDC":"72485010905"},{"Id":416970,"FormularyType":"OHP","DrugName":"CAFFEINE CIT SOL 60MG/3ML","DosageForm":"SOLN - Solution","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"ANALEPTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"1","AgeMaxUnit":"Y","GenericProductIdentifier":"61300010102060","GenericName":"CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)","NDC":"72485011010"},{"Id":416971,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"72485020290"},{"Id":416972,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"72485020330"},{"Id":416973,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"72485020460"},{"Id":416974,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"72485020512"},{"Id":416975,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100320","GenericName":"ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","NDC":"72485021730"},{"Id":416976,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100330","GenericName":"ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","NDC":"72485021830"},{"Id":416977,"FormularyType":"OHP","DrugName":"ERLOTINIB TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - EGFR INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21360025100360","GenericName":"ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","NDC":"72485021930"},{"Id":416978,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"72485040301"},{"Id":416979,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"72485040310"},{"Id":416980,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"72485040401"},{"Id":416981,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"72485040410"},{"Id":416982,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"72485040601"},{"Id":416983,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"72485040610"},{"Id":416984,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102120","GenericName":"OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT)","NDC":"72485040901"},{"Id":416985,"FormularyType":"OHP","DrugName":"OXACILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300050102120","GenericName":"OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT)","NDC":"72485040910"},{"Id":416986,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"72485041110"},{"Id":416987,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"72485041201"},{"Id":416988,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"72485041210"},{"Id":416989,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"72485041601"},{"Id":416990,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"72485041610"},{"Id":416991,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"72485041701"},{"Id":416992,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"72485041710"},{"Id":416993,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"72485041801"},{"Id":416994,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"72485041815"},{"Id":416995,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"72485042101"},{"Id":416996,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"72485042110"},{"Id":416997,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72485042201"},{"Id":416998,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72485042210"},{"Id":416999,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"72485042301"},{"Id":417000,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"72485042310"},{"Id":417001,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2% JELLY","DosageForm":"GEL - Gel","Strength":"2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060104006","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL 2%","NDC":"72485061110"},{"Id":417002,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2% JELLY","DosageForm":"GEL - Gel","Strength":"2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060104006","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL 2%","NDC":"72485061130"},{"Id":417003,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2% JELLY","DosageForm":"GEL - Gel","Strength":"2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060104006","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL 2%","NDC":"72485061131"},{"Id":417004,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"72485061310"},{"Id":417005,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"72485061311"},{"Id":417006,"FormularyType":"OHP","DrugName":"KETOTIF FUM DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"72485061710"},{"Id":417007,"FormularyType":"OHP","DrugName":"CIPRO/DEXA SUS 0.3-0.1%","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87991002361820","GenericName":"CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","NDC":"72485062513"},{"Id":417008,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN OIN 0.5% OP","DosageForm":"OINT - Ointment","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101025004210","GenericName":"ERYTHROMYCIN OPHTH OINT 5 MG/GM","NDC":"72485067031"},{"Id":417009,"FormularyType":"OHP","DrugName":"ERYTHROMYCIN OIN 0.5% OP","DosageForm":"OINT - Ointment","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101025004210","GenericName":"ERYTHROMYCIN OPHTH OINT 5 MG/GM","NDC":"72485067035"},{"Id":417010,"FormularyType":"OHP","DrugName":"REPATHA SURE INJ 140MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935002000D520","GenericName":"EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","NDC":"72511039301"},{"Id":417011,"FormularyType":"OHP","DrugName":"REPATHA SURE INJ 140MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935002000D520","GenericName":"EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","NDC":"72511039302"},{"Id":417012,"FormularyType":"OHP","DrugName":"REPATHA INJ 140MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935002000E520","GenericName":"EVOLOCUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 140 MG/ML","NDC":"72511050101"},{"Id":417013,"FormularyType":"OHP","DrugName":"REPATHA SURE INJ 140MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935002000D520","GenericName":"EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","NDC":"72511076001"},{"Id":417014,"FormularyType":"OHP","DrugName":"REPATHA SURE INJ 140MG/ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"140","BrandVsGeneric":"N","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3935002000D520","GenericName":"EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","NDC":"72511076002"},{"Id":417015,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 30MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100330","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","NDC":"72516001101"},{"Id":417016,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 20MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100320","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","NDC":"72516001201"},{"Id":417017,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 15MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100315","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","NDC":"72516001301"},{"Id":417018,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100310","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","NDC":"72516001401"},{"Id":417019,"FormularyType":"OHP","DrugName":"AMPHET/DEXTR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61109902100305","GenericName":"AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","NDC":"72516001601"},{"Id":417020,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72516002610"},{"Id":417021,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72516002710"},{"Id":417022,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"72516002801"},{"Id":417023,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"72516002901"},{"Id":417024,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"72516003001"},{"Id":417025,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"72516003010"},{"Id":417026,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"72516003050"},{"Id":417027,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72516003101"},{"Id":417028,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72516003110"},{"Id":417029,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72516003150"},{"Id":417030,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72516003201"},{"Id":417031,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72516003210"},{"Id":417032,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72516003250"},{"Id":417033,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"72516003301"},{"Id":417034,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"72572001601"},{"Id":417035,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"72572001610"},{"Id":417036,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72572001701"},{"Id":417037,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72572001710"},{"Id":417038,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"72572002901"},{"Id":417039,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"72572002910"},{"Id":417040,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72572004001"},{"Id":417041,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72572004010"},{"Id":417042,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72572004101"},{"Id":417043,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"72572004110"},{"Id":417044,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"72572005501"},{"Id":417045,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102115","GenericName":"CEFAZOLIN SODIUM FOR INJ 1 GM","NDC":"72572005525"},{"Id":417046,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"72572005601"},{"Id":417047,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02100015102125","GenericName":"CEFAZOLIN SODIUM FOR INJ 10 GM","NDC":"72572005610"},{"Id":417048,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"72572006101"},{"Id":417049,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102115","GenericName":"CEFTRIAXONE SODIUM FOR INJ 1 GM","NDC":"72572006125"},{"Id":417050,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"72572006201"},{"Id":417051,"FormularyType":"OHP","DrugName":"CEFTRIAXONE INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 3RD GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"02300090102120","GenericName":"CEFTRIAXONE SODIUM FOR INJ 2 GM","NDC":"72572006225"},{"Id":417052,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"72572007401"},{"Id":417053,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 600/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312030","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 600 MG/50ML","NDC":"72572007424"},{"Id":417054,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"72572007601"},{"Id":417055,"FormularyType":"OHP","DrugName":"CLINDAMY/D5W INJ 900/50ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"LINCOSAMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16220020312040","GenericName":"CLINDAMYCIN PHOSPHATE IN D5W IV SOLN 900 MG/50ML","NDC":"72572007624"},{"Id":417056,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72572009401"},{"Id":417057,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72572009410"},{"Id":417058,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"72572009701"},{"Id":417059,"FormularyType":"OHP","DrugName":"METHYLPR SS INJ 40MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100030202105","GenericName":"METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","NDC":"72572009725"},{"Id":417060,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"72572010501"},{"Id":417061,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252122","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 3 (2-1) GM","NDC":"72572013601"},{"Id":417062,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252122","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 3 (2-1) GM","NDC":"72572013610"},{"Id":417063,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72572019001"},{"Id":417064,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72572019025"},{"Id":417065,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"72572020701"},{"Id":417066,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72572025001"},{"Id":417067,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72572025025"},{"Id":417068,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72572025501"},{"Id":417069,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72572025525"},{"Id":417070,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"72572028001"},{"Id":417071,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"72572028010"},{"Id":417072,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"72572038001"},{"Id":417073,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"72572038025"},{"Id":417074,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"72572041001"},{"Id":417075,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"72572041010"},{"Id":417076,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"72572041201"},{"Id":417077,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"72572041210"},{"Id":417078,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"72572041401"},{"Id":417079,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"72572041410"},{"Id":417080,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"72572041501"},{"Id":417081,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002120","GenericName":"MEROPENEM IV FOR SOLN 500 MG","NDC":"72572041510"},{"Id":417082,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"72572041601"},{"Id":417083,"FormularyType":"OHP","DrugName":"MEROPENEM INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"CARBAPENEMS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16150050002140","GenericName":"MEROPENEM IV FOR SOLN 1 GM","NDC":"72572041610"},{"Id":417084,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"72572041801"},{"Id":417085,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"72572041810"},{"Id":417086,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"72572043201"},{"Id":417087,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102003","GenericName":"MIDAZOLAM HCL INJ 5 MG/5ML (BASE EQUIVALENT)","NDC":"72572043210"},{"Id":417088,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"72572045001"},{"Id":417089,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"72572045025"},{"Id":417090,"FormularyType":"OHP","DrugName":"METRONIDAZOL INJ 500MG","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035002030","GenericName":"METRONIDAZOLE IV SOLN 500 MG/100ML","NDC":"72572054024"},{"Id":417091,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"72572057301"},{"Id":417092,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"72572057310"},{"Id":417093,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"72572057401"},{"Id":417094,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"72572057410"},{"Id":417095,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"72572074025"},{"Id":417096,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"72572074701"},{"Id":417097,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"72572074710"},{"Id":417098,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"72572080101"},{"Id":417099,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 1 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102120","GenericName":"VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","NDC":"72572080102"},{"Id":417100,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102125","GenericName":"VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","NDC":"72572080301"},{"Id":417101,"FormularyType":"OHP","DrugName":"VANCOMYCIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"GLYCOPEPTIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16280080102130","GenericName":"VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","NDC":"72572080501"},{"Id":417102,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"72578000105"},{"Id":417103,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100310","GenericName":"DOXYCYCLINE HYCLATE TAB 100 MG","NDC":"72578000118"},{"Id":417104,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"72578000201"},{"Id":417105,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"72578000205"},{"Id":417106,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"72578000305"},{"Id":417107,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"72578000314"},{"Id":417108,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"72578000405"},{"Id":417109,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"72578000414"},{"Id":417110,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"72578000701"},{"Id":417111,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"72578000705"},{"Id":417112,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000305","GenericName":"METRONIDAZOLE TAB 250 MG","NDC":"72578000721"},{"Id":417113,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"72578000801"},{"Id":417114,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"72578000805"},{"Id":417115,"FormularyType":"OHP","DrugName":"METRONIDAZOL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000035000310","GenericName":"METRONIDAZOLE TAB 500 MG","NDC":"72578000818"},{"Id":417116,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"72578003601"},{"Id":417117,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"72578004001"},{"Id":417118,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"72578004101"},{"Id":417119,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"72578004201"},{"Id":417120,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"72578004205"},{"Id":417121,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100105","GenericName":"DOXYCYCLINE HYCLATE CAP 50 MG","NDC":"72578005418"},{"Id":417122,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"72578005505"},{"Id":417123,"FormularyType":"OHP","DrugName":"DOXYCYCL HYC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"TETRACYCLINES","DrugSubClass":"TETRACYCLINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"04000020100110","GenericName":"DOXYCYCLINE HYCLATE CAP 100 MG","NDC":"72578005518"},{"Id":417124,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"72578005601"},{"Id":417125,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000310","GenericName":"FELBAMATE TAB 400 MG","NDC":"72578005616"},{"Id":417126,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"72578005701"},{"Id":417127,"FormularyType":"OHP","DrugName":"FELBAMATE TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"CARBAMATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72120020000320","GenericName":"FELBAMATE TAB 600 MG","NDC":"72578005716"},{"Id":417128,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000320","GenericName":"VORICONAZOLE TAB 50 MG","NDC":"72578006206"},{"Id":417129,"FormularyType":"OHP","DrugName":"VORICONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407080000340","GenericName":"VORICONAZOLE TAB 200 MG","NDC":"72578006306"},{"Id":417130,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"72578006414"},{"Id":417131,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"72578006514"},{"Id":417132,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72578006605"},{"Id":417133,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72578006614"},{"Id":417134,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"72578008101"},{"Id":417135,"FormularyType":"OHP","DrugName":"SUCRALFATE TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010000305","GenericName":"SUCRALFATE TAB 1 GM","NDC":"72578008105"},{"Id":417136,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"72578008402"},{"Id":417137,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"72578008403"},{"Id":417138,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"72578008801"},{"Id":417139,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"72578008802"},{"Id":417140,"FormularyType":"OHP","DrugName":"NYSTAT/TRIAM OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90159902254200","GenericName":"NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","NDC":"72578008804"},{"Id":417141,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"72578008901"},{"Id":417142,"FormularyType":"OHP","DrugName":"NYSTATIN OIN 100000","DosageForm":"OINT - Ointment","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080004215","GenericName":"NYSTATIN OINT 100000 UNIT/GM","NDC":"72578008904"},{"Id":417143,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"72578009001"},{"Id":417144,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ CAP 37.5-25","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300105","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","NDC":"72578009010"},{"Id":417145,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"72578009101"},{"Id":417146,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"72578009102"},{"Id":417147,"FormularyType":"OHP","DrugName":"DESOXIMETAS CRE 0.25%","DosageForm":"CREA - Cream","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550040003710","GenericName":"DESOXIMETASONE CREAM 0.25%","NDC":"72578009103"},{"Id":417148,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"72578009301"},{"Id":417149,"FormularyType":"OHP","DrugName":"BETAMETH DIP OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550020004205","GenericName":"BETAMETHASONE DIPROPIONATE OINT 0.05%","NDC":"72578009306"},{"Id":417150,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"72578009610"},{"Id":417151,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100310","GenericName":"TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","NDC":"72578009621"},{"Id":417152,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"72578009710"},{"Id":417153,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"72578009721"},{"Id":417154,"FormularyType":"OHP","DrugName":"TIZANIDINE TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100090100320","GenericName":"TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","NDC":"72578009776"},{"Id":417155,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000320","GenericName":"LEVOFLOXACIN TAB 250 MG","NDC":"72578009818"},{"Id":417156,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000330","GenericName":"LEVOFLOXACIN TAB 500 MG","NDC":"72578009918"},{"Id":417157,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"72578010006"},{"Id":417158,"FormularyType":"OHP","DrugName":"LEVOFLOXACIN TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000034000340","GenericName":"LEVOFLOXACIN TAB 750 MG","NDC":"72578010092"},{"Id":417159,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"72578011101"},{"Id":417160,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"72578011106"},{"Id":417161,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"72578011201"},{"Id":417162,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"72578011206"},{"Id":417163,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"72578011301"},{"Id":417164,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"72578011305"},{"Id":417165,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 2.5/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130310","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","NDC":"72578011306"},{"Id":417166,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"72578011401"},{"Id":417167,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"72578011405"},{"Id":417168,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 5-6.25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130320","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","NDC":"72578011406"},{"Id":417169,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"72578011501"},{"Id":417170,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"72578011505"},{"Id":417171,"FormularyType":"OHP","DrugName":"BISOPRL/HCTZ TAB 10/6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36992002130330","GenericName":"BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","NDC":"72578011506"},{"Id":417172,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"72578011801"},{"Id":417173,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"72578011802"},{"Id":417174,"FormularyType":"OHP","DrugName":"METRONIDAZOL CRE 0.75%","DosageForm":"CREA - Cream","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040003710","GenericName":"METRONIDAZOLE CREAM 0.75%","NDC":"72578012908"},{"Id":417175,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"72578013106"},{"Id":417176,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"72578013216"},{"Id":417177,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"72578013316"},{"Id":417178,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"72578013416"},{"Id":417179,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000320","GenericName":"FEBUXOSTAT TAB 40 MG","NDC":"72578013606"},{"Id":417180,"FormularyType":"OHP","DrugName":"FEBUXOSTAT TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000030000330","GenericName":"FEBUXOSTAT TAB 80 MG","NDC":"72578013706"},{"Id":417181,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"72578013801"},{"Id":417182,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"72578013805"},{"Id":417183,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"72578014714"},{"Id":417184,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"72578014806"},{"Id":417185,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"72578014901"},{"Id":417186,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"72578015001"},{"Id":417187,"FormularyType":"OHP","DrugName":"KETOCONAZOLE SHA 2%","DosageForm":"SHAM - Shampoo","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004510","GenericName":"KETOCONAZOLE SHAMPOO 2%","NDC":"72578015612"},{"Id":417188,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"72578016401"},{"Id":417189,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"72578016405"},{"Id":417190,"FormularyType":"OHP","DrugName":"LIDO/PRILOCN CRE 2.5-2.5%","DosageForm":"CREA - Cream","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90859902903710","GenericName":"LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","NDC":"72578016506"},{"Id":417191,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000325","GenericName":"DEXAMETHASONE TAB 1 MG","NDC":"72578016601"},{"Id":417192,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"72578016701"},{"Id":417193,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"72578016801"},{"Id":417194,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"72578016901"},{"Id":417195,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"72578017001"},{"Id":417196,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"72578017101"},{"Id":417197,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"72578017201"},{"Id":417198,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 300MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007440","GenericName":"THEOPHYLLINE TAB ER 12HR 300 MG","NDC":"72578017301"},{"Id":417199,"FormularyType":"OHP","DrugName":"THEOPHYLLINE TAB 450MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"XANTHINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44300040007455","GenericName":"THEOPHYLLINE TAB ER 12HR 450 MG","NDC":"72578017401"},{"Id":417200,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ROSACEA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90060040004010","GenericName":"METRONIDAZOLE GEL 0.75%","NDC":"72578020904"},{"Id":417201,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"72578021201"},{"Id":417202,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"72578021301"},{"Id":417203,"FormularyType":"OHP","DrugName":"BRUKINSA CAP 80MG","DosageForm":"CAPS - Capsule","Strength":"80","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532195000120","GenericName":"ZANUBRUTINIB CAP 80 MG","NDC":"72579001102"},{"Id":417204,"FormularyType":"OHP","DrugName":"BRUKINSA TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532195000330","GenericName":"ZANUBRUTINIB TAB 160 MG","NDC":"72579012201"},{"Id":417205,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"72603011001"},{"Id":417206,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"72603011101"},{"Id":417207,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"72603011501"},{"Id":417208,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"72603011502"},{"Id":417209,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100320","GenericName":"MEMANTINE HCL TAB 5 MG","NDC":"72603011801"},{"Id":417210,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"72603011901"},{"Id":417211,"FormularyType":"OHP","DrugName":"MEMANTINE TAB HCL 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62053550100330","GenericName":"MEMANTINE HCL TAB 10 MG","NDC":"72603011902"},{"Id":417212,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"72603012901"},{"Id":417213,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"72603013001"},{"Id":417214,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"72603013101"},{"Id":417215,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"72603013201"},{"Id":417216,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72603013301"},{"Id":417217,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72603013325"},{"Id":417218,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"72603013401"},{"Id":417219,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"72603013402"},{"Id":417220,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000305","GenericName":"SPIRONOLACTONE TAB 25 MG","NDC":"72603013403"},{"Id":417221,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"72603013501"},{"Id":417222,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000310","GenericName":"SPIRONOLACTONE TAB 50 MG","NDC":"72603013502"},{"Id":417223,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"72603013601"},{"Id":417224,"FormularyType":"OHP","DrugName":"SPIRONOLACT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"POTASSIUM SPARING DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37500020000315","GenericName":"SPIRONOLACTONE TAB 100 MG","NDC":"72603013602"},{"Id":417225,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"72603014101"},{"Id":417226,"FormularyType":"OHP","DrugName":"SUMATRIPTAN INJ 6MG/.5ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6740607010D520","GenericName":"SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","NDC":"72603014102"},{"Id":417227,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"72603014201"},{"Id":417228,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"72603014202"},{"Id":417229,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"72603014203"},{"Id":417230,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72603014301"},{"Id":417231,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72603014302"},{"Id":417232,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"72603014303"},{"Id":417233,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72603014401"},{"Id":417234,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72603014402"},{"Id":417235,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"72603014403"},{"Id":417236,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"72603014501"},{"Id":417237,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"72603014502"},{"Id":417238,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"72603016201"},{"Id":417239,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000303","GenericName":"METHAZOLAMIDE TAB 25 MG","NDC":"72603016601"},{"Id":417240,"FormularyType":"OHP","DrugName":"METHAZOLAMID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100030000305","GenericName":"METHAZOLAMIDE TAB 50 MG","NDC":"72603016701"},{"Id":417241,"FormularyType":"OHP","DrugName":"PROCHLORPER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIPSYCHOTICS/ANTIMANIC AGENTS","DrugSubClass":"PHENOTHIAZINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"59200055100310","GenericName":"PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","NDC":"72603016901"},{"Id":417242,"FormularyType":"OHP","DrugName":"FLUDROCORT TAB 0.1MG","DosageForm":"TABS - Tablet","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"MINERALOCORTICOIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22200030100305","GenericName":"FLUDROCORTISONE ACETATE TAB 0.1 MG","NDC":"72603017001"},{"Id":417243,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"72603017101"},{"Id":417244,"FormularyType":"OHP","DrugName":"VALGANCICLOV SOL 50MG/ML","DosageForm":"SOLR - Solution Reconstituted","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12200066102120","GenericName":"VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","NDC":"72603017401"},{"Id":417245,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"72603017701"},{"Id":417246,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"72603017801"},{"Id":417247,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/10","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603017901"},{"Id":417248,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/10","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603017925"},{"Id":417249,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100110","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG","NDC":"72603018201"},{"Id":417250,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100115","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","NDC":"72603018301"},{"Id":417251,"FormularyType":"OHP","DrugName":"NITROFUR MAC CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050100120","GenericName":"NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","NDC":"72603018401"},{"Id":417252,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"72603018601"},{"Id":417253,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3%OTIC","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OTIC AGENTS","DrugSubClass":"OTIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"87100060002010","GenericName":"OFLOXACIN OTIC SOLN 0.3%","NDC":"72603018602"},{"Id":417254,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"72603018701"},{"Id":417255,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"72603018801"},{"Id":417256,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"72603018901"},{"Id":417257,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"72603019001"},{"Id":417258,"FormularyType":"OHP","DrugName":"SAPROPTERIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565100320","GenericName":"SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG","NDC":"72603019101"},{"Id":417259,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"72603019201"},{"Id":417260,"FormularyType":"OHP","DrugName":"OFLOXACIN DRO 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101047002020","GenericName":"OFLOXACIN OPHTH SOLN 0.3%","NDC":"72603019202"},{"Id":417261,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"72603019301"},{"Id":417262,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"72603019330"},{"Id":417263,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"72603019401"},{"Id":417264,"FormularyType":"OHP","DrugName":"SAPROPTERIN POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"72603019430"},{"Id":417265,"FormularyType":"OHP","DrugName":"NITROFURANTN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800050150120","GenericName":"NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","NDC":"72603019601"},{"Id":417266,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72603020601"},{"Id":417267,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72603020602"},{"Id":417268,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"72603020901"},{"Id":417269,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"72603020925"},{"Id":417270,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"72603021001"},{"Id":417271,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"72603021010"},{"Id":417272,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"72603021201"},{"Id":417273,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"72603021301"},{"Id":417274,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 50000/10","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72603021401"},{"Id":417275,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 50000/10","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72603021425"},{"Id":417276,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"72603022001"},{"Id":417277,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"72603022010"},{"Id":417278,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"72603022101"},{"Id":417279,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 500MG","DosageForm":"SOLR - Solution Reconstituted","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302115","GenericName":"AMPICILLIN SODIUM FOR INJ 500 MG","NDC":"72603022110"},{"Id":417280,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"72603022401"},{"Id":417281,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"72603022425"},{"Id":417282,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000320","GenericName":"DEFERASIROX TAB 90 MG","NDC":"72603023101"},{"Id":417283,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000330","GenericName":"DEFERASIROX TAB 180 MG","NDC":"72603023201"},{"Id":417284,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"72603023301"},{"Id":417285,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603023401"},{"Id":417286,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603023425"},{"Id":417287,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"72603023901"},{"Id":417288,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"72603024801"},{"Id":417289,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603025001"},{"Id":417290,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603025025"},{"Id":417291,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72603025101"},{"Id":417292,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72603025125"},{"Id":417293,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"72603025201"},{"Id":417294,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000310","GenericName":"EVEROLIMUS TAB 2.5 MG","NDC":"72603025401"},{"Id":417295,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000320","GenericName":"EVEROLIMUS TAB 5 MG","NDC":"72603025501"},{"Id":417296,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000325","GenericName":"EVEROLIMUS TAB 7.5 MG","NDC":"72603025601"},{"Id":417297,"FormularyType":"OHP","DrugName":"EVEROLIMUS TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532530000330","GenericName":"EVEROLIMUS TAB 10 MG","NDC":"72603025701"},{"Id":417298,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"72603025801"},{"Id":417299,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"72603025803"},{"Id":417300,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"72603025901"},{"Id":417301,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72603026301"},{"Id":417302,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72603026302"},{"Id":417303,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"72603026401"},{"Id":417304,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"72603026402"},{"Id":417305,"FormularyType":"OHP","DrugName":"TESTOSTERONE GEL 1.62%","DosageForm":"GEL - Gel","Strength":"1.62","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030004050","GenericName":"TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)","NDC":"72603026501"},{"Id":417306,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"72603026601"},{"Id":417307,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"72603026604"},{"Id":417308,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 30000/30","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603026701"},{"Id":417309,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 30000/30","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"72603026725"},{"Id":417310,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72603027101"},{"Id":417311,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72603027102"},{"Id":417312,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72603027201"},{"Id":417313,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72603027202"},{"Id":417314,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000303","GenericName":"ESTRADIOL TAB 0.5 MG","NDC":"72603027301"},{"Id":417315,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"72603027401"},{"Id":417316,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000305","GenericName":"ESTRADIOL TAB 1 MG","NDC":"72603027402"},{"Id":417317,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"72603027501"},{"Id":417318,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ESTROGENS","DrugSubClass":"ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"24000035000310","GenericName":"ESTRADIOL TAB 2 MG","NDC":"72603027502"},{"Id":417319,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72603028201"},{"Id":417320,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72603028202"},{"Id":417321,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72603028203"},{"Id":417322,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72603028301"},{"Id":417323,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72603028302"},{"Id":417324,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72603028303"},{"Id":417325,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72603028401"},{"Id":417326,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72603028402"},{"Id":417327,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72603028403"},{"Id":417328,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72603028501"},{"Id":417329,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72603028502"},{"Id":417330,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72603028503"},{"Id":417331,"FormularyType":"OHP","DrugName":"TESTOST CYP INJ 200MG/ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANDROGENS-ANABOLIC","DrugSubClass":"ANDROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"23100030102015","GenericName":"TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","NDC":"72603028601"},{"Id":417332,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"72603029001"},{"Id":417333,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500320","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"72603029002"},{"Id":417334,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"72603029101"},{"Id":417335,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500340","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","NDC":"72603029102"},{"Id":417336,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"72603029201"},{"Id":417337,"FormularyType":"OHP","DrugName":"OLM MED/HCTZ TAB 40-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36994002500345","GenericName":"OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","NDC":"72603029202"},{"Id":417338,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"72603030202"},{"Id":417339,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"72603030203"},{"Id":417340,"FormularyType":"OHP","DrugName":"POLYETH GLYC POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"72603030204"},{"Id":417341,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"72603030301"},{"Id":417342,"FormularyType":"OHP","DrugName":"MESALAMINE TAB 1.2GM","DosageForm":"TBEC - Tablet DR","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500030000670","GenericName":"MESALAMINE TAB DELAYED RELEASE 1.2 GM","NDC":"72603030401"},{"Id":417343,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"72603030501"},{"Id":417344,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"72603030701"},{"Id":417345,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"72603030702"},{"Id":417346,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72603030801"},{"Id":417347,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72603030802"},{"Id":417348,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72603030803"},{"Id":417349,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"72603030901"},{"Id":417350,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"72603030902"},{"Id":417351,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"72603031001"},{"Id":417352,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"72603031002"},{"Id":417353,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"72603031201"},{"Id":417354,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"72603031202"},{"Id":417355,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"72603031203"},{"Id":417356,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000305","GenericName":"METHIMAZOLE TAB 5 MG","NDC":"72603031501"},{"Id":417357,"FormularyType":"OHP","DrugName":"METHIMAZOLE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"ANTITHYROID AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28300010000310","GenericName":"METHIMAZOLE TAB 10 MG","NDC":"72603031601"},{"Id":417358,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"72603032101"},{"Id":417359,"FormularyType":"OHP","DrugName":"CLINDAMYCIN SOL 1%","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010102005","GenericName":"CLINDAMYCIN PHOSPHATE SOLN 1%","NDC":"72603032102"},{"Id":417360,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"72603032301"},{"Id":417361,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"72603032302"},{"Id":417362,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"72603032303"},{"Id":417363,"FormularyType":"OHP","DrugName":"CLOBETASOL CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025103705","GenericName":"CLOBETASOL PROPIONATE CREAM 0.05%","NDC":"72603032304"},{"Id":417364,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"72603032801"},{"Id":417365,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"72603032802"},{"Id":417366,"FormularyType":"OHP","DrugName":"EXEMESTANE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402835000320","GenericName":"EXEMESTANE TAB 25 MG","NDC":"72603032901"},{"Id":417367,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"72603033501"},{"Id":417368,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"72603033510"},{"Id":417369,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"72603033701"},{"Id":417370,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"72603033801"},{"Id":417371,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72603034001"},{"Id":417372,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72603034002"},{"Id":417373,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72603034101"},{"Id":417374,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72603034102"},{"Id":417375,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72603034201"},{"Id":417376,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72603034202"},{"Id":417377,"FormularyType":"OHP","DrugName":"LEUPROLIDE INJ 14 DAY","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"72603034401"},{"Id":417378,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 20MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"20000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102135","GenericName":"PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","NDC":"72603034501"},{"Id":417379,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"72603035201"},{"Id":417380,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"72603035301"},{"Id":417381,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"72603035401"},{"Id":417382,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"72603035501"},{"Id":417383,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"72603035601"},{"Id":417384,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"72603035701"},{"Id":417385,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"72603035801"},{"Id":417386,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"72603036301"},{"Id":417387,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 1GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302120","GenericName":"AMPICILLIN SODIUM FOR INJ 1 GM","NDC":"72603036310"},{"Id":417388,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"72603036401"},{"Id":417389,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"72603036402"},{"Id":417390,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"72603036501"},{"Id":417391,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"72603036502"},{"Id":417392,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"72603036601"},{"Id":417393,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"72603036602"},{"Id":417394,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"72603036603"},{"Id":417395,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72603036701"},{"Id":417396,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72603036702"},{"Id":417397,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72603036703"},{"Id":417398,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"72603036704"},{"Id":417399,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"72603039801"},{"Id":417400,"FormularyType":"OHP","DrugName":"SEVELAM CARB POW 0.8GM","DosageForm":"PACK - Packet","Strength":"0.8","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070053020","GenericName":"SEVELAMER CARBONATE PACKET 0.8 GM","NDC":"72603039802"},{"Id":417401,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72603040301"},{"Id":417402,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"72603040302"},{"Id":417403,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72603040401"},{"Id":417404,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"72603040402"},{"Id":417405,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72603040501"},{"Id":417406,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"72603040502"},{"Id":417407,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72603040601"},{"Id":417408,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"72603040602"},{"Id":417409,"FormularyType":"OHP","DrugName":"SIROLIMUS SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404070002020","GenericName":"SIROLIMUS ORAL SOLN 1 MG/ML","NDC":"72603040901"},{"Id":417410,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72603041201"},{"Id":417411,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72603041225"},{"Id":417412,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"72603043004"},{"Id":417413,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"72603043056"},{"Id":417414,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"72603044401"},{"Id":417415,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"72603045301"},{"Id":417416,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102115","GenericName":"NAFCILLIN SODIUM FOR INJ 2 GM","NDC":"72603045310"},{"Id":417417,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72603045401"},{"Id":417418,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 2GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302125","GenericName":"AMPICILLIN SODIUM FOR INJ 2 GM","NDC":"72603045410"},{"Id":417419,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72603045601"},{"Id":417420,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"72603045625"},{"Id":417421,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72603047401"},{"Id":417422,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"72603047425"},{"Id":417423,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200320","GenericName":"VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","NDC":"72603047601"},{"Id":417424,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100080200330","GenericName":"VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","NDC":"72603047701"},{"Id":417425,"FormularyType":"OHP","DrugName":"VARENICLINE TAB 0.5& 1MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6210008020B720","GenericName":"VARENICLINE TARTRATE TAB 11 X 0.5 MG & 42 X 1 MG START PACK","NDC":"72603047801"},{"Id":417426,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"72603049101"},{"Id":417427,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"72603049102"},{"Id":417428,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"72603049103"},{"Id":417429,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"72603050101"},{"Id":417430,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"72603050125"},{"Id":417431,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"72603054001"},{"Id":417432,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"72603056701"},{"Id":417433,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"72603057801"},{"Id":417434,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"72603057901"},{"Id":417435,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"72603057925"},{"Id":417436,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"72603059010"},{"Id":417437,"FormularyType":"OHP","DrugName":"NALOXONE INJ 0.4MG/ML","DosageForm":"SOLN - Solution","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020102010","GenericName":"NALOXONE HCL INJ 0.4 MG/ML","NDC":"72603059025"},{"Id":417438,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 25MG DR","DosageForm":"TBEC - Tablet DR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200610","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG","NDC":"72603060001"},{"Id":417439,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"72603060101"},{"Id":417440,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72603060401"},{"Id":417441,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72603060402"},{"Id":417442,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72603060403"},{"Id":417443,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"72603060501"},{"Id":417444,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"72603060601"},{"Id":417445,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"72603060701"},{"Id":417446,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"72603060901"},{"Id":417447,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"72603060902"},{"Id":417448,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"72603061001"},{"Id":417449,"FormularyType":"OHP","DrugName":"AZELASTINE SPR 0.1%","DosageForm":"SOLN - Solution","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTIALLERGY","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42401015102020","GenericName":"AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","NDC":"72603061101"},{"Id":417450,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"72603061301"},{"Id":417451,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"72603065001"},{"Id":417452,"FormularyType":"OHP","DrugName":"CYANOCOBALAM INJ 1000MCG","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010002015","GenericName":"CYANOCOBALAMIN INJ 1000 MCG/ML","NDC":"72603065025"},{"Id":417453,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"72603066001"},{"Id":417454,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"72603066002"},{"Id":417455,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"72603066101"},{"Id":417456,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"72603066201"},{"Id":417457,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"72603066301"},{"Id":417458,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"72603066401"},{"Id":417459,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"72603066402"},{"Id":417460,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"72603066501"},{"Id":417461,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"72603066601"},{"Id":417462,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"72603066701"},{"Id":417463,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"72603066801"},{"Id":417464,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"72603066802"},{"Id":417465,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"72603066901"},{"Id":417466,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000310","GenericName":"IRBESARTAN TAB 75 MG","NDC":"72603067001"},{"Id":417467,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000320","GenericName":"IRBESARTAN TAB 150 MG","NDC":"72603067101"},{"Id":417468,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"72603067201"},{"Id":417469,"FormularyType":"OHP","DrugName":"IRBESARTAN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150030000340","GenericName":"IRBESARTAN TAB 300 MG","NDC":"72603067202"},{"Id":417470,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"72603070101"},{"Id":417471,"FormularyType":"OHP","DrugName":"FLUOCINONIDE SOL 0.05%","DosageForm":"SOLN - Solution","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550060002005","GenericName":"FLUOCINONIDE SOLN 0.05%","NDC":"72603070301"},{"Id":417472,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 16MG","DosageForm":"TABS - Tablet","Strength":"16","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100330","GenericName":"CANDESARTAN CILEXETIL TAB 16 MG","NDC":"72603072001"},{"Id":417473,"FormularyType":"OHP","DrugName":"CANDESARTAN TAB 32MG","DosageForm":"TABS - Tablet","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150020100340","GenericName":"CANDESARTAN CILEXETIL TAB 32 MG","NDC":"72603072101"},{"Id":417474,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"72603074502"},{"Id":417475,"FormularyType":"OHP","DrugName":"LIRAGLUTIDE INJ 18MG/3ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INCRETIN MIMETIC AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2717005000D220","GenericName":"LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","NDC":"72603074503"},{"Id":417476,"FormularyType":"OHP","DrugName":"VALGANCICLOV TAB 450MG","DosageForm":"TABS - Tablet","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"CMV AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12200066100320","GenericName":"VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","NDC":"72603075001"},{"Id":417477,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT SUS 200MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030101920","GenericName":"MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","NDC":"72603075101"},{"Id":417478,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000310","GenericName":"TELMISARTAN TAB 20 MG","NDC":"72603083101"},{"Id":417479,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000320","GenericName":"TELMISARTAN TAB 40 MG","NDC":"72603083201"},{"Id":417480,"FormularyType":"OHP","DrugName":"TELMISARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150070000340","GenericName":"TELMISARTAN TAB 80 MG","NDC":"72603083301"},{"Id":417481,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 54MG","DosageForm":"TABS - Tablet","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000312","GenericName":"FENOFIBRATE TAB 54 MG","NDC":"72603084001"},{"Id":417482,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"72603084101"},{"Id":417483,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000325","GenericName":"FENOFIBRATE TAB 160 MG","NDC":"72603084102"},{"Id":417484,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"72603085501"},{"Id":417485,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"72603085502"},{"Id":417486,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"72603085503"},{"Id":417487,"FormularyType":"OHP","DrugName":"CLOBETASOL OIN 0.05%","DosageForm":"OINT - Ointment","Strength":"0.05","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550025104205","GenericName":"CLOBETASOL PROPIONATE OINT 0.05%","NDC":"72603085504"},{"Id":417488,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"72603087408"},{"Id":417489,"FormularyType":"OHP","DrugName":"ESTRADIOL TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ESTROGENS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55350020000310","GenericName":"ESTRADIOL VAGINAL TAB 10 MCG","NDC":"72603087418"},{"Id":417490,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"72603087501"},{"Id":417491,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"72603087503"},{"Id":417492,"FormularyType":"OHP","DrugName":"KETOCONAZOLE SHA 2%","DosageForm":"SHAM - Shampoo","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154045004510","GenericName":"KETOCONAZOLE SHAMPOO 2%","NDC":"72603087801"},{"Id":417493,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"72611074901"},{"Id":417494,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 50/10ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102050","GenericName":"MIDAZOLAM HCL INJ 50 MG/10ML (BASE EQUIVALENT)","NDC":"72611074910"},{"Id":417495,"FormularyType":"OHP","DrugName":"SOFOS/VELPAT TAB 400-100","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"M","DrugCategory":"ANTIVIRALS","DrugSubClass":"HEPATITIS AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12359902650330","GenericName":"SOFOSBUVIR-VELPATASVIR TAB 400-100 MG","NDC":"72626270101"},{"Id":417496,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"72627243001"},{"Id":417497,"FormularyType":"OHP","DrugName":"SHEWISE TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"72657010812"},{"Id":417498,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"72657011220"},{"Id":417499,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"72657011290"},{"Id":417500,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72657011320"},{"Id":417501,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72657011388"},{"Id":417502,"FormularyType":"OHP","DrugName":"LEVONORGESTR TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400040000340","GenericName":"LEVONORGESTREL TAB 1.5 MG","NDC":"72657012311"},{"Id":417503,"FormularyType":"OHP","DrugName":"CETIRIZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"72657012935"},{"Id":417504,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72657013201"},{"Id":417505,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"72657015817"},{"Id":417506,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"72657015855"},{"Id":417507,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"72657016850"},{"Id":417508,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"72657019411"},{"Id":417509,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"72657019425"},{"Id":417510,"FormularyType":"OHP","DrugName":"LAXATIVE POW OSMOTIC","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"72657019616"},{"Id":417511,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"72664021101"},{"Id":417512,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"72664021201"},{"Id":417513,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"72664021301"},{"Id":417514,"FormularyType":"OHP","DrugName":"URSODIOL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GALLSTONE SOLUBILIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52100040000120","GenericName":"URSODIOL CAP 300 MG","NDC":"72664021701"},{"Id":417515,"FormularyType":"OHP","DrugName":"LEUPROLIDE KIT 1MG/0.2","DosageForm":"KIT - Kit","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"72664061128"},{"Id":417516,"FormularyType":"OHP","DrugName":"XUREA CRE 39%","DosageForm":"CREA - Cream","Strength":"39","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080003724","GenericName":"UREA CREAM 39%","NDC":"72678003401"},{"Id":417517,"FormularyType":"OHP","DrugName":"TIBSOVO TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21534940000320","GenericName":"IVOSIDENIB TAB 250 MG","NDC":"72694061760"},{"Id":417518,"FormularyType":"OHP","DrugName":"VORANIGO TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535180000340","GenericName":"VORASIDENIB TAB 40 MG","NDC":"72694072840"},{"Id":417519,"FormularyType":"OHP","DrugName":"VORANIGO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535180000320","GenericName":"VORASIDENIB TAB 10 MG","NDC":"72694087910"},{"Id":417520,"FormularyType":"OHP","DrugName":"ORLADEYO CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLASMA KALLIKREIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85840010200130","GenericName":"BEROTRALSTAT HCL CAP 150 MG","NDC":"72769010101"},{"Id":417521,"FormularyType":"OHP","DrugName":"ORLADEYO CAP 110MG","DosageForm":"CAPS - Capsule","Strength":"110","BrandVsGeneric":"N","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLASMA KALLIKREIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85840010200120","GenericName":"BEROTRALSTAT HCL CAP 110 MG","NDC":"72769010201"},{"Id":417522,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"72789043601"},{"Id":417523,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"72789051495"},{"Id":417524,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"72789051530"},{"Id":417525,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"72789051590"},{"Id":417526,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"72789051595"},{"Id":417527,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"72789051630"},{"Id":417528,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"72789051690"},{"Id":417529,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"72789051695"},{"Id":417530,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052201"},{"Id":417531,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052228"},{"Id":417532,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052230"},{"Id":417533,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052290"},{"Id":417534,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052293"},{"Id":417535,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052295"},{"Id":417536,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"72789052298"},{"Id":417537,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"72819015110"},{"Id":417538,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"72819015508"},{"Id":417539,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"72819015608"},{"Id":417540,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000310","GenericName":"VALSARTAN TAB 40 MG","NDC":"72819018103"},{"Id":417541,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000320","GenericName":"VALSARTAN TAB 80 MG","NDC":"72819018209"},{"Id":417542,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000330","GenericName":"VALSARTAN TAB 160 MG","NDC":"72819018309"},{"Id":417543,"FormularyType":"OHP","DrugName":"VALSARTAN TAB 320MG","DosageForm":"TABS - Tablet","Strength":"320","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150080000340","GenericName":"VALSARTAN TAB 320 MG","NDC":"72819018409"},{"Id":417544,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"72819018509"},{"Id":417545,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"72819018603"},{"Id":417546,"FormularyType":"OHP","DrugName":"GLUCO TO GO GEL 40%","DosageForm":"GEL - Gel","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030004020","GenericName":"GLUCOSE GEL 40%","NDC":"72847021315"},{"Id":417547,"FormularyType":"OHP","DrugName":"GLUCO TO GO CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"72847022150"},{"Id":417548,"FormularyType":"OHP","DrugName":"CAPZIX CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"72847031620"},{"Id":417549,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100356","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","NDC":"72865011001"},{"Id":417550,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100358","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","NDC":"72865011101"},{"Id":417551,"FormularyType":"OHP","DrugName":"HYDROCO/APAP TAB 10-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65991702100305","GenericName":"HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","NDC":"72865011201"},{"Id":417552,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 5-325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200310","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","NDC":"72865011401"},{"Id":417553,"FormularyType":"OHP","DrugName":"OXYCOD/APAP TAB 7.5-325","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65990002200327","GenericName":"OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","NDC":"72865011501"},{"Id":417554,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"72865011701"},{"Id":417555,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000105","GenericName":"BENZONATATE CAP 100 MG","NDC":"72865011730"},{"Id":417556,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"72865011901"},{"Id":417557,"FormularyType":"OHP","DrugName":"BENZONATATE CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"ANTITUSSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43102010000110","GenericName":"BENZONATATE CAP 200 MG","NDC":"72865011930"},{"Id":417558,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"72865012201"},{"Id":417559,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"72865012301"},{"Id":417560,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"72865012401"},{"Id":417561,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100325","GenericName":"OXYCODONE HCL TAB 15 MG","NDC":"72865012801"},{"Id":417562,"FormularyType":"OHP","DrugName":"OXYCODONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100075100340","GenericName":"OXYCODONE HCL TAB 30 MG","NDC":"72865012901"},{"Id":417563,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 18MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"18","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100460","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG","NDC":"72865013301"},{"Id":417564,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 27MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"27","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100465","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","NDC":"72865013401"},{"Id":417565,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 36MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"36","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100470","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","NDC":"72865013501"},{"Id":417566,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 54MG OSM","DosageForm":"TBCR - Tablet ER","Strength":"54","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100480","GenericName":"METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","NDC":"72865013601"},{"Id":417567,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"72865014030"},{"Id":417568,"FormularyType":"OHP","DrugName":"DUTASTERIDE CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851020000120","GenericName":"DUTASTERIDE CAP 0.5 MG","NDC":"72865014090"},{"Id":417569,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72865014110"},{"Id":417570,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72865014130"},{"Id":417571,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"72865014190"},{"Id":417572,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72865014210"},{"Id":417573,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72865014230"},{"Id":417574,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"72865014290"},{"Id":417575,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72865014310"},{"Id":417576,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72865014330"},{"Id":417577,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"72865014390"},{"Id":417578,"FormularyType":"OHP","DrugName":"LAMIVUD/ZIDO TAB 150-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902500320","GenericName":"LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG","NDC":"72865014460"},{"Id":417579,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000105","GenericName":"INDOMETHACIN CAP 25 MG","NDC":"72865014801"},{"Id":417580,"FormularyType":"OHP","DrugName":"INDOMETHACIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100030000110","GenericName":"INDOMETHACIN CAP 50 MG","NDC":"72865014901"},{"Id":417581,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"72865015030"},{"Id":417582,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"72865015130"},{"Id":417583,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"72865015230"},{"Id":417584,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"72865016701"},{"Id":417585,"FormularyType":"OHP","DrugName":"ABACAVIR TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12105005100320","GenericName":"ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","NDC":"72865016760"},{"Id":417586,"FormularyType":"OHP","DrugName":"EFAVIRENZ TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109030000330","GenericName":"EFAVIRENZ TAB 600 MG","NDC":"72865017230"},{"Id":417587,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"72865017510"},{"Id":417588,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"72865017530"},{"Id":417589,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"72865017590"},{"Id":417590,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72865018605"},{"Id":417591,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72865018618"},{"Id":417592,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"72865018660"},{"Id":417593,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"72865018705"},{"Id":417594,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"72865018712"},{"Id":417595,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"72865018805"},{"Id":417596,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"72865018812"},{"Id":417597,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"72865018905"},{"Id":417598,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"72865018912"},{"Id":417599,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"72865019060"},{"Id":417600,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 540MG","DosageForm":"TBCR - Tablet ER","Strength":"540","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200420","GenericName":"POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","NDC":"72865019101"},{"Id":417601,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1080MG","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200440","GenericName":"POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","NDC":"72865019201"},{"Id":417602,"FormularyType":"OHP","DrugName":"POT CITRA ER TAB 1620MG","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202010200460","GenericName":"POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","NDC":"72865019301"},{"Id":417603,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"72865019401"},{"Id":417604,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100430","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","NDC":"72865019405"},{"Id":417605,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"72865019601"},{"Id":417606,"FormularyType":"OHP","DrugName":"POT CL MICRO TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030100440","GenericName":"POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","NDC":"72865019605"},{"Id":417607,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"72865020945"},{"Id":417608,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"72865020990"},{"Id":417609,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"72865021010"},{"Id":417610,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"72865021045"},{"Id":417611,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"72865021090"},{"Id":417612,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"72865021110"},{"Id":417613,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"72865021145"},{"Id":417614,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"72865021190"},{"Id":417615,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"72865021310"},{"Id":417616,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"72865021345"},{"Id":417617,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"72865021390"},{"Id":417618,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72865021401"},{"Id":417619,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72865021405"},{"Id":417620,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"72865021418"},{"Id":417621,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72865021501"},{"Id":417622,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72865021505"},{"Id":417623,"FormularyType":"OHP","DrugName":"FAMOTIDINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000340","GenericName":"FAMOTIDINE TAB 40 MG","NDC":"72865021518"},{"Id":417624,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"72865022990"},{"Id":417625,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"72865023010"},{"Id":417626,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"72865023090"},{"Id":417627,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000320","GenericName":"MARAVIROC TAB 150 MG","NDC":"72865023160"},{"Id":417628,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000330","GenericName":"MARAVIROC TAB 300 MG","NDC":"72865023260"},{"Id":417629,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"72865023301"},{"Id":417630,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"72865023305"},{"Id":417631,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"72865023401"},{"Id":417632,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"72865023405"},{"Id":417633,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72865023501"},{"Id":417634,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"72865023510"},{"Id":417635,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"72865023610"},{"Id":417636,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100305","GenericName":"LEVOTHYROXINE SODIUM TAB 25 MCG","NDC":"72865023690"},{"Id":417637,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"72865023710"},{"Id":417638,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100310","GenericName":"LEVOTHYROXINE SODIUM TAB 50 MCG","NDC":"72865023790"},{"Id":417639,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"72865023810"},{"Id":417640,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 75MCG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100315","GenericName":"LEVOTHYROXINE SODIUM TAB 75 MCG","NDC":"72865023890"},{"Id":417641,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"72865023910"},{"Id":417642,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 88MCG","DosageForm":"TABS - Tablet","Strength":"88","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100317","GenericName":"LEVOTHYROXINE SODIUM TAB 88 MCG","NDC":"72865023990"},{"Id":417643,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"72865024010"},{"Id":417644,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100320","GenericName":"LEVOTHYROXINE SODIUM TAB 100 MCG","NDC":"72865024090"},{"Id":417645,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"72865024110"},{"Id":417646,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 112MCG","DosageForm":"TABS - Tablet","Strength":"112","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100322","GenericName":"LEVOTHYROXINE SODIUM TAB 112 MCG","NDC":"72865024190"},{"Id":417647,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"72865024210"},{"Id":417648,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100325","GenericName":"LEVOTHYROXINE SODIUM TAB 125 MCG","NDC":"72865024290"},{"Id":417649,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"72865024310"},{"Id":417650,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 137MCG","DosageForm":"TABS - Tablet","Strength":"137","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100327","GenericName":"LEVOTHYROXINE SODIUM TAB 137 MCG","NDC":"72865024390"},{"Id":417651,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"72865024410"},{"Id":417652,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 150MCG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100330","GenericName":"LEVOTHYROXINE SODIUM TAB 150 MCG","NDC":"72865024490"},{"Id":417653,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"72865024510"},{"Id":417654,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 175MCG","DosageForm":"TABS - Tablet","Strength":"175","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100335","GenericName":"LEVOTHYROXINE SODIUM TAB 175 MCG","NDC":"72865024590"},{"Id":417655,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"72865024610"},{"Id":417656,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 200MCG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100340","GenericName":"LEVOTHYROXINE SODIUM TAB 200 MCG","NDC":"72865024690"},{"Id":417657,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"72865024710"},{"Id":417658,"FormularyType":"OHP","DrugName":"LEVOTHYROXIN TAB 300MCG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100010100345","GenericName":"LEVOTHYROXINE SODIUM TAB 300 MCG","NDC":"72865024790"},{"Id":417659,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"72865025205"},{"Id":417660,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"72865025218"},{"Id":417661,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"72865025227"},{"Id":417662,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"72865025290"},{"Id":417663,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"72865025305"},{"Id":417664,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"72865025318"},{"Id":417665,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"72865025327"},{"Id":417666,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"72865025330"},{"Id":417667,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"72865025360"},{"Id":417668,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"72865025390"},{"Id":417669,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"72865025405"},{"Id":417670,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"72865025427"},{"Id":417671,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"72865025490"},{"Id":417672,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"72865025730"},{"Id":417673,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000310","GenericName":"TORSEMIDE TAB 5 MG","NDC":"72865025890"},{"Id":417674,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"72865025901"},{"Id":417675,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000320","GenericName":"TORSEMIDE TAB 10 MG","NDC":"72865025990"},{"Id":417676,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"72865026001"},{"Id":417677,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"72865026005"},{"Id":417678,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000330","GenericName":"TORSEMIDE TAB 20 MG","NDC":"72865026090"},{"Id":417679,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"72865026101"},{"Id":417680,"FormularyType":"OHP","DrugName":"TORSEMIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200080000350","GenericName":"TORSEMIDE TAB 100 MG","NDC":"72865026190"},{"Id":417681,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200120","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","NDC":"72865027260"},{"Id":417682,"FormularyType":"OHP","DrugName":"DABIGATRAN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"THROMBIN INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83337030200140","GenericName":"DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","NDC":"72865027360"},{"Id":417683,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"72865028205"},{"Id":417684,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"72865028290"},{"Id":417685,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"72865028301"},{"Id":417686,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"72865028305"},{"Id":417687,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72865028401"},{"Id":417688,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72865028405"},{"Id":417689,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72865028501"},{"Id":417690,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72865028505"},{"Id":417691,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 0.5GM","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100110","GenericName":"ICOSAPENT ETHYL CAP 0.5 GM","NDC":"72865028924"},{"Id":417692,"FormularyType":"OHP","DrugName":"ICOSAPENT CAP 1GM","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"ANTIHYPERLIPIDEMICS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39500035100120","GenericName":"ICOSAPENT ETHYL CAP 1 GM","NDC":"72865029012"},{"Id":417693,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100310","GenericName":"ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","NDC":"72865029930"},{"Id":417694,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100320","GenericName":"ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","NDC":"72865030030"},{"Id":417695,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100330","GenericName":"ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","NDC":"72865030130"},{"Id":417696,"FormularyType":"OHP","DrugName":"ELTROMBOPAG TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"HEMATOPOIETIC GROWTH FACTORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82405030100340","GenericName":"ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","NDC":"72865030230"},{"Id":417697,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"72865030301"},{"Id":417698,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000305","GenericName":"ALLOPURINOL TAB 100 MG","NDC":"72865030310"},{"Id":417699,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"72865030401"},{"Id":417700,"FormularyType":"OHP","DrugName":"ALLOPURINOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"GOUT AGENTS","DrugSubClass":"GOUT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"68000010000310","GenericName":"ALLOPURINOL TAB 300 MG","NDC":"72865030405"},{"Id":417701,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"72865031310"},{"Id":417702,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"72865031360"},{"Id":417703,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"72865031410"},{"Id":417704,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"72865031460"},{"Id":417705,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"72865031510"},{"Id":417706,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"72865031560"},{"Id":417707,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"72865031610"},{"Id":417708,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"72865031660"},{"Id":417709,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"72865033201"},{"Id":417710,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"72865033210"},{"Id":417711,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"72865033290"},{"Id":417712,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"72865033301"},{"Id":417713,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"72865033310"},{"Id":417714,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"72865033390"},{"Id":417715,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888000400"},{"Id":417716,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888000401"},{"Id":417717,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888000405"},{"Id":417718,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"72888000500"},{"Id":417719,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"72888000501"},{"Id":417720,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"72888000600"},{"Id":417721,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"72888000601"},{"Id":417722,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"72888000901"},{"Id":417723,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"72888001000"},{"Id":417724,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"72888001001"},{"Id":417725,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"72888001005"},{"Id":417726,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"72888001100"},{"Id":417727,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"72888001101"},{"Id":417728,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"72888001105"},{"Id":417729,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"72888001200"},{"Id":417730,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"72888001201"},{"Id":417731,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"72888001205"},{"Id":417732,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"72888001400"},{"Id":417733,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"72888001401"},{"Id":417734,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"72888001405"},{"Id":417735,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"72888001800"},{"Id":417736,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"72888001890"},{"Id":417737,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"72888001901"},{"Id":417738,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"72888002001"},{"Id":417739,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"72888002101"},{"Id":417740,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100312","GenericName":"METOPROLOL TARTRATE TAB 75 MG","NDC":"72888002301"},{"Id":417741,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"72888002909"},{"Id":417742,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"72888002911"},{"Id":417743,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"72888003001"},{"Id":417744,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 5MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207520","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","NDC":"72888003005"},{"Id":417745,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"72888003101"},{"Id":417746,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207530","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","NDC":"72888003105"},{"Id":417747,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"72888003201"},{"Id":417748,"FormularyType":"OHP","DrugName":"OXYBUTYNIN TAB 15MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100045207540","GenericName":"OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","NDC":"72888003205"},{"Id":417749,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"72888003301"},{"Id":417750,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"72888003305"},{"Id":417751,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"72888003330"},{"Id":417752,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"72888003400"},{"Id":417753,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"72888003401"},{"Id":417754,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"72888003405"},{"Id":417755,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"72888003500"},{"Id":417756,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"72888003501"},{"Id":417757,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"72888003505"},{"Id":417758,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"72888003600"},{"Id":417759,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"72888003601"},{"Id":417760,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"72888003605"},{"Id":417761,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"72888003700"},{"Id":417762,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"72888003701"},{"Id":417763,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"72888003705"},{"Id":417764,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"72888003905"},{"Id":417765,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"72888003960"},{"Id":417766,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"72888004113"},{"Id":417767,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"72888004213"},{"Id":417768,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"72888004501"},{"Id":417769,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"72888004505"},{"Id":417770,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"72888004601"},{"Id":417771,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"72888004605"},{"Id":417772,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"72888004701"},{"Id":417773,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"72888004801"},{"Id":417774,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"72888005201"},{"Id":417775,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"72888005301"},{"Id":417776,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"72888005401"},{"Id":417777,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"72888005930"},{"Id":417778,"FormularyType":"OHP","DrugName":"RABEPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270076100620","GenericName":"RABEPRAZOLE SODIUM EC TAB 20 MG","NDC":"72888005990"},{"Id":417779,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"72888007301"},{"Id":417780,"FormularyType":"OHP","DrugName":"DICLOFEN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007100330","GenericName":"DICLOFENAC POTASSIUM TAB 50 MG","NDC":"72888007305"},{"Id":417781,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN SUS 300/5ML","DosageForm":"SUSP - Suspension","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600046001820","GenericName":"OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","NDC":"72888007414"},{"Id":417782,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"72888007500"},{"Id":417783,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"72888007501"},{"Id":417784,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 10MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000430","GenericName":"POTASSIUM CHLORIDE TAB ER 10 MEQ","NDC":"72888007505"},{"Id":417785,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000445","GenericName":"POTASSIUM CHLORIDE TAB ER 20 MEQ (1500 MG)","NDC":"72888007601"},{"Id":417786,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 20MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000445","GenericName":"POTASSIUM CHLORIDE TAB ER 20 MEQ (1500 MG)","NDC":"72888007605"},{"Id":417787,"FormularyType":"OHP","DrugName":"DORZOLAMIDE SOL 2% OP","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802340102020","GenericName":"DORZOLAMIDE HCL OPHTH SOLN 2%","NDC":"72888007715"},{"Id":417788,"FormularyType":"OHP","DrugName":"ACYCLOVIR SUS 200/5ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"12405010001810","GenericName":"ACYCLOVIR SUSP 200 MG/5ML","NDC":"72888007917"},{"Id":417789,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"72888008000"},{"Id":417790,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"72888008001"},{"Id":417791,"FormularyType":"OHP","DrugName":"TRAMADOL HCL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100095100320","GenericName":"TRAMADOL HCL TAB 50 MG","NDC":"72888008005"},{"Id":417792,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"72888008100"},{"Id":417793,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000305","GenericName":"ISOSORBIDE DINITRATE TAB 5 MG","NDC":"72888008101"},{"Id":417794,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"72888008200"},{"Id":417795,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000310","GenericName":"ISOSORBIDE DINITRATE TAB 10 MG","NDC":"72888008201"},{"Id":417796,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"72888008300"},{"Id":417797,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000315","GenericName":"ISOSORBIDE DINITRATE TAB 20 MG","NDC":"72888008301"},{"Id":417798,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"72888008400"},{"Id":417799,"FormularyType":"OHP","DrugName":"ISOSORB DIN TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100020000320","GenericName":"ISOSORBIDE DINITRATE TAB 30 MG","NDC":"72888008401"},{"Id":417800,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"72888008701"},{"Id":417801,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"72888008705"},{"Id":417802,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72888008801"},{"Id":417803,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72888008805"},{"Id":417804,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72888008901"},{"Id":417805,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72888008905"},{"Id":417806,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"72888009201"},{"Id":417807,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100310","GenericName":"BISOPROLOL FUMARATE TAB 5 MG","NDC":"72888009230"},{"Id":417808,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"72888009301"},{"Id":417809,"FormularyType":"OHP","DrugName":"BISOPROL FUM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200022100320","GenericName":"BISOPROLOL FUMARATE TAB 10 MG","NDC":"72888009330"},{"Id":417810,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"72888009401"},{"Id":417811,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 37.5-25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300315","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","NDC":"72888009405"},{"Id":417812,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"72888009501"},{"Id":417813,"FormularyType":"OHP","DrugName":"TRIAMT/HCTZ TAB 75-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"DIURETIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37990002300330","GenericName":"TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","NDC":"72888009505"},{"Id":417814,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 37.5MG","DosageForm":"TABS - Tablet","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100307","GenericName":"METOPROLOL TARTRATE TAB 37.5 MG","NDC":"72888010101"},{"Id":417815,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"72888010221"},{"Id":417816,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"72888010222"},{"Id":417817,"FormularyType":"OHP","DrugName":"CIPROFLOXACN SOL 0.3% OP","DosageForm":"SOLN - Solution","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86101023102010","GenericName":"CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","NDC":"72888010223"},{"Id":417818,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"72888010425"},{"Id":417819,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"72888010600"},{"Id":417820,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"72888010601"},{"Id":417821,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"72888010605"},{"Id":417822,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"72888010700"},{"Id":417823,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"72888010701"},{"Id":417824,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"72888010705"},{"Id":417825,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"72888010800"},{"Id":417826,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"72888010801"},{"Id":417827,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"72888010805"},{"Id":417828,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 25MG DR","DosageForm":"TBEC - Tablet DR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200610","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG","NDC":"72888010901"},{"Id":417829,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"72888011000"},{"Id":417830,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"72888011001"},{"Id":417831,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 50MG DR","DosageForm":"TBEC - Tablet DR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200620","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","NDC":"72888011060"},{"Id":417832,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72888011100"},{"Id":417833,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72888011101"},{"Id":417834,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72888011105"},{"Id":417835,"FormularyType":"OHP","DrugName":"DICLOFENAC TAB 75MG DR","DosageForm":"TBEC - Tablet DR","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100007200630","GenericName":"DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","NDC":"72888011160"},{"Id":417836,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"72888011201"},{"Id":417837,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"72888011301"},{"Id":417838,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"72888011401"},{"Id":417839,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"72888011600"},{"Id":417840,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"72888011601"},{"Id":417841,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000305","GenericName":"GLIPIZIDE TAB 5 MG","NDC":"72888011605"},{"Id":417842,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"72888011700"},{"Id":417843,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"72888011701"},{"Id":417844,"FormularyType":"OHP","DrugName":"GLIPIZIDE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"SULFONYLUREAS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27200030000310","GenericName":"GLIPIZIDE TAB 10 MG","NDC":"72888011705"},{"Id":417845,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"72888011900"},{"Id":417846,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"72888011901"},{"Id":417847,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"72888012001"},{"Id":417848,"FormularyType":"OHP","DrugName":"LABETALOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100305","GenericName":"LABETALOL HCL TAB 100 MG","NDC":"72888012005"},{"Id":417849,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"72888012101"},{"Id":417850,"FormularyType":"OHP","DrugName":"LABETALOL TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100310","GenericName":"LABETALOL HCL TAB 200 MG","NDC":"72888012105"},{"Id":417851,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"72888012201"},{"Id":417852,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"72888012205"},{"Id":417853,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"72888012301"},{"Id":417854,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"72888012401"},{"Id":417855,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 2% ORAL","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102050","GenericName":"LIDOCAINE HCL VISCOUS SOLN 2%","NDC":"72888012526"},{"Id":417856,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"72888013001"},{"Id":417857,"FormularyType":"OHP","DrugName":"LOPERAMIDE CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100020100105","GenericName":"LOPERAMIDE HCL CAP 2 MG","NDC":"72888013005"},{"Id":417858,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"72888013101"},{"Id":417859,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"72888013105"},{"Id":417860,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"72888013201"},{"Id":417861,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"72888013205"},{"Id":417862,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.3","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000710","GenericName":"NITROGLYCERIN SL TAB 0.3 MG","NDC":"72888013801"},{"Id":417863,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"72888013901"},{"Id":417864,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"72888013932"},{"Id":417865,"FormularyType":"OHP","DrugName":"NITROGLYCERN SUB 0.4MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000715","GenericName":"NITROGLYCERIN SL TAB 0.4 MG","NDC":"72888013933"},{"Id":417866,"FormularyType":"OHP","DrugName":"NITROGLYCERI SUB 0.6MG","DosageForm":"SUBL - Tab Sublingual","Strength":"0.6","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100030000720","GenericName":"NITROGLYCERIN SL TAB 0.6 MG","NDC":"72888014001"},{"Id":417867,"FormularyType":"OHP","DrugName":"FLUTICASONE SPR 50MCG","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200032301810","GenericName":"FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT","NDC":"72888014135"},{"Id":417868,"FormularyType":"OHP","DrugName":"IPRATROPIUM SPR 0.03%","DosageForm":"SOLN - Solution","Strength":"0.03","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42300040102010","GenericName":"IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","NDC":"72888014938"},{"Id":417869,"FormularyType":"OHP","DrugName":"DICLOFENAC SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805010102010","GenericName":"DICLOFENAC SODIUM OPHTH SOLN 0.1%","NDC":"72888015021"},{"Id":417870,"FormularyType":"OHP","DrugName":"DICLOFENAC SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86805010102010","GenericName":"DICLOFENAC SODIUM OPHTH SOLN 0.1%","NDC":"72888015022"},{"Id":417871,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"72888015200"},{"Id":417872,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"72888015201"},{"Id":417873,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"72888015205"},{"Id":417874,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000305","GenericName":"CLONAZEPAM TAB 0.5 MG","NDC":"72888015230"},{"Id":417875,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72888015300"},{"Id":417876,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72888015301"},{"Id":417877,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72888015305"},{"Id":417878,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000310","GenericName":"CLONAZEPAM TAB 1 MG","NDC":"72888015330"},{"Id":417879,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"72888015400"},{"Id":417880,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"72888015401"},{"Id":417881,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"72888015405"},{"Id":417882,"FormularyType":"OHP","DrugName":"CLONAZEPAM TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"64","AgeMaxUnit":"Y","GenericProductIdentifier":"72100010000315","GenericName":"CLONAZEPAM TAB 2 MG","NDC":"72888015430"},{"Id":417883,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"72888015501"},{"Id":417884,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"72888015530"},{"Id":417885,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"72888015601"},{"Id":417886,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"72888015630"},{"Id":417887,"FormularyType":"OHP","DrugName":"TRANEX ACID TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"HEMOSTATICS","DrugSubClass":"HEMOSTATICS - SYSTEMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"84100040000320","GenericName":"TRANEXAMIC ACID TAB 650 MG","NDC":"72888017830"},{"Id":417888,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 2MG","DosageForm":"SUBL - Tab Sublingual","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100760","GenericName":"BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","NDC":"72888018230"},{"Id":417889,"FormularyType":"OHP","DrugName":"BUPRENORPHIN SUB 8MG","DosageForm":"SUBL - Tab Sublingual","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID PARTIAL AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65200010100780","GenericName":"BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","NDC":"72888018330"},{"Id":417890,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"72888018501"},{"Id":417891,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100330","GenericName":"MYCOPHENOLATE MOFETIL TAB 500 MG","NDC":"72888018505"},{"Id":417892,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"72888019201"},{"Id":417893,"FormularyType":"OHP","DrugName":"MYCOPHENOLAT CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030100120","GenericName":"MYCOPHENOLATE MOFETIL CAP 250 MG","NDC":"72888019205"},{"Id":417894,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 180MG DR","DosageForm":"TBEC - Tablet DR","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300620","GenericName":"MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"72888019912"},{"Id":417895,"FormularyType":"OHP","DrugName":"MYCOPHENOLIC TAB 360MG DR","DosageForm":"TBEC - Tablet DR","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99403030300630","GenericName":"MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","NDC":"72888020012"},{"Id":417896,"FormularyType":"OHP","DrugName":"POT CHLORIDE TAB 15MEQ ER","DosageForm":"TBCR - Tablet ER","Strength":"15","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030000435","GenericName":"POTASSIUM CHLORIDE TAB ER 15 MEQ","NDC":"72888020101"},{"Id":417897,"FormularyType":"OHP","DrugName":"IVERMECTIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000007000310","GenericName":"IVERMECTIN TAB 3 MG","NDC":"72888020666"},{"Id":417898,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888020800"},{"Id":417899,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888020801"},{"Id":417900,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888020802"},{"Id":417901,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"72888020805"},{"Id":417902,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"72888021000"},{"Id":417903,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"72888021001"},{"Id":417904,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"72888021002"},{"Id":417905,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"72888021200"},{"Id":417906,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"72888021201"},{"Id":417907,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150320","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"72888022001"},{"Id":417908,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150330","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"72888022101"},{"Id":417909,"FormularyType":"OHP","DrugName":"BENAZEP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802150340","GenericName":"BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"72888022201"},{"Id":417910,"FormularyType":"OHP","DrugName":"TOPIRAMATE CAP 50MG","DosageForm":"CPSP - Capsule Sprinkle","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075006840","GenericName":"TOPIRAMATE SPRINKLE CAP 50 MG","NDC":"72888023030"},{"Id":417911,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000315","GenericName":"DEXAMETHASONE TAB 0.5 MG","NDC":"72888023501"},{"Id":417912,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 0.75MG","DosageForm":"TABS - Tablet","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000320","GenericName":"DEXAMETHASONE TAB 0.75 MG","NDC":"72888023601"},{"Id":417913,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000325","GenericName":"DEXAMETHASONE TAB 1 MG","NDC":"72888023701"},{"Id":417914,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 1.5MG","DosageForm":"TABS - Tablet","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000330","GenericName":"DEXAMETHASONE TAB 1.5 MG","NDC":"72888023801"},{"Id":417915,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000335","GenericName":"DEXAMETHASONE TAB 2 MG","NDC":"72888023901"},{"Id":417916,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000340","GenericName":"DEXAMETHASONE TAB 4 MG","NDC":"72888024001"},{"Id":417917,"FormularyType":"OHP","DrugName":"DEXAMETHASON TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020000345","GenericName":"DEXAMETHASONE TAB 6 MG","NDC":"72888024101"},{"Id":417918,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"72888045901"},{"Id":417919,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72888046001"},{"Id":417920,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000320","GenericName":"OXCARBAZEPINE TAB 300 MG","NDC":"72888046002"},{"Id":417921,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72888046101"},{"Id":417922,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000340","GenericName":"OXCARBAZEPINE TAB 600 MG","NDC":"72888046102"},{"Id":417923,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"72888046201"},{"Id":417924,"FormularyType":"OHP","DrugName":"OXCARBAZEPIN TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600046000310","GenericName":"OXCARBAZEPINE TAB 150 MG","NDC":"72888046202"},{"Id":417925,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"72888046801"},{"Id":417926,"FormularyType":"OHP","DrugName":"LABETALOL TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300010100315","GenericName":"LABETALOL HCL TAB 300 MG","NDC":"72888046802"},{"Id":417927,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"72888049901"},{"Id":417928,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"72888049902"},{"Id":417929,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"72888050001"},{"Id":417930,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"72888050002"},{"Id":417931,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"72888050102"},{"Id":417932,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"72888050201"},{"Id":417933,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"72888050202"},{"Id":417934,"FormularyType":"OHP","DrugName":"YUTREPIA CAP 26.5MCG","DosageForm":"CAPS - Capsule","Strength":"26.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080100110","GenericName":"TREPROSTINIL SODIUM INHAL CAP 26.5 MCG","NDC":"72964001101"},{"Id":417935,"FormularyType":"OHP","DrugName":"YUTREPIA CAP 53MCG","DosageForm":"CAPS - Capsule","Strength":"53","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080100120","GenericName":"TREPROSTINIL SODIUM INHAL CAP 53 MCG","NDC":"72964001201"},{"Id":417936,"FormularyType":"OHP","DrugName":"YUTREPIA CAP 79.5MCG","DosageForm":"CAPS - Capsule","Strength":"79.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080100130","GenericName":"TREPROSTINIL SODIUM INHAL CAP 79.5 MCG","NDC":"72964001301"},{"Id":417937,"FormularyType":"OHP","DrugName":"YUTREPIA CAP 106MCG","DosageForm":"CAPS - Capsule","Strength":"106","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PROSTAGLANDIN VASODILATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40170080100140","GenericName":"TREPROSTINIL SODIUM INHAL CAP 106 MCG","NDC":"72964001401"},{"Id":417938,"FormularyType":"OHP","DrugName":"ORGOVYX TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405570000320","GenericName":"RELUGOLIX TAB 120 MG","NDC":"72974012001"},{"Id":417939,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"73043000801"},{"Id":417940,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"73043000802"},{"Id":417941,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"73043000803"},{"Id":417942,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"73043000901"},{"Id":417943,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"73043000902"},{"Id":417944,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201935","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","NDC":"73043000903"},{"Id":417945,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"73043001001"},{"Id":417946,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"73043001002"},{"Id":417947,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"73043001003"},{"Id":417948,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"73043001105"},{"Id":417949,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"73043001114"},{"Id":417950,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"73043001205"},{"Id":417951,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"73043001214"},{"Id":417952,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"73043001305"},{"Id":417953,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"73043001314"},{"Id":417954,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"73043001405"},{"Id":417955,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"73043001414"},{"Id":417956,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"73043001505"},{"Id":417957,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"73043001514"},{"Id":417958,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"73043001605"},{"Id":417959,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"73043002201"},{"Id":417960,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"73043002291"},{"Id":417961,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"73043002301"},{"Id":417962,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"73043002391"},{"Id":417963,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"73043002401"},{"Id":417964,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 100/10ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"73043002491"},{"Id":417965,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"73043003801"},{"Id":417966,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"73043003828"},{"Id":417967,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"73043003901"},{"Id":417968,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"73043003928"},{"Id":417969,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"73043004001"},{"Id":417970,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"73043004028"},{"Id":417971,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"73043004101"},{"Id":417972,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"73043004121"},{"Id":417973,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"73043004201"},{"Id":417974,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"73043004221"},{"Id":417975,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"73043004301"},{"Id":417976,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"73043004321"},{"Id":417977,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"73086021001"},{"Id":417978,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"73086021101"},{"Id":417979,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"73086021201"},{"Id":417980,"FormularyType":"OHP","DrugName":"SELEGILINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73300030100320","GenericName":"SELEGILINE HCL TAB 5 MG","NDC":"73141000602"},{"Id":417981,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100320","GenericName":"GUANFACINE HCL TAB 1 MG","NDC":"73141001804"},{"Id":417982,"FormularyType":"OHP","DrugName":"GUANFACINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36201025100330","GenericName":"GUANFACINE HCL TAB 2 MG","NDC":"73141001904"},{"Id":417983,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"73141002102"},{"Id":417984,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"73141002202"},{"Id":417985,"FormularyType":"OHP","DrugName":"POSACONAZOLE TAB 100MG DR","DosageForm":"TBEC - Tablet DR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407060000620","GenericName":"POSACONAZOLE TAB DELAYED RELEASE 100 MG","NDC":"73141002302"},{"Id":417986,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000320","GenericName":"MARAVIROC TAB 150 MG","NDC":"73141002402"},{"Id":417987,"FormularyType":"OHP","DrugName":"MARAVIROC TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12102060000330","GenericName":"MARAVIROC TAB 300 MG","NDC":"73141002502"},{"Id":417988,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"73141010405"},{"Id":417989,"FormularyType":"OHP","DrugName":"ATOVAQUONE SUS 750/5ML","DosageForm":"SUSP - Suspension","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTIPROTOZOAL AGENTS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16400020001820","GenericName":"ATOVAQUONE SUSP 750 MG/5ML","NDC":"73141010442"},{"Id":417990,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"73141011601"},{"Id":417991,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"73141011701"},{"Id":417992,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"73141011801"},{"Id":417993,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"73141013501"},{"Id":417994,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"73141055802"},{"Id":417995,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"73141062228"},{"Id":417996,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"73141062254"},{"Id":417997,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200320","GenericName":"TOLTERODINE TARTRATE TAB 1 MG","NDC":"73152002660"},{"Id":417998,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"73152002705"},{"Id":417999,"FormularyType":"OHP","DrugName":"TOLTERODINE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100060200330","GenericName":"TOLTERODINE TARTRATE TAB 2 MG","NDC":"73152002760"},{"Id":418000,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"73152007501"},{"Id":418001,"FormularyType":"OHP","DrugName":"AMANTADINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100310","GenericName":"AMANTADINE HCL TAB 100 MG","NDC":"73152007505"},{"Id":418002,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"73152007601"},{"Id":418003,"FormularyType":"OHP","DrugName":"AMANTADINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73200010100105","GenericName":"AMANTADINE HCL CAP 100 MG","NDC":"73152007605"},{"Id":418004,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"73152014101"},{"Id":418005,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"73152014110"},{"Id":418006,"FormularyType":"OHP","DrugName":"DESMOPRESSIN SOL 1.5MG/ML","DosageForm":"SOLN - Solution","Strength":"1.5","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102015","GenericName":"DESMOPRESSIN ACETATE NASAL SOLN 1.5 MG/ML","NDC":"73177011415"},{"Id":418007,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"73190000510"},{"Id":418008,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"73190000518"},{"Id":418009,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"73190000560"},{"Id":418010,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"73190000610"},{"Id":418011,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"73190000618"},{"Id":418012,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"73190000660"},{"Id":418013,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"73190000710"},{"Id":418014,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"73190000718"},{"Id":418015,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"73190000760"},{"Id":418016,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"73190001427"},{"Id":418017,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 48MG","DosageForm":"TABS - Tablet","Strength":"48","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000310","GenericName":"FENOFIBRATE TAB 48 MG","NDC":"73190001590"},{"Id":418018,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"73190001690"},{"Id":418019,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"73190001718"},{"Id":418020,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"73190001760"},{"Id":418021,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"73190001818"},{"Id":418022,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"73190001860"},{"Id":418023,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"73190001918"},{"Id":418024,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"73190001960"},{"Id":418025,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"73190003260"},{"Id":418026,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"73190003411"},{"Id":418027,"FormularyType":"OHP","DrugName":"NILOTINB HCL CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531860200125","GenericName":"NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT)","NDC":"73190003412"},{"Id":418028,"FormularyType":"OHP","DrugName":"DEFERASIROX TAB 360MG","DosageForm":"TABS - Tablet","Strength":"360","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"ANTIDOTES - CHELATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93100025000340","GenericName":"DEFERASIROX TAB 360 MG","NDC":"73190005230"},{"Id":418029,"FormularyType":"OHP","DrugName":"QINLOCK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533053000320","GenericName":"RIPRETINIB TAB 50 MG","NDC":"73207010130"},{"Id":418030,"FormularyType":"OHP","DrugName":"ROMVIMZA CAP 14MG","DosageForm":"CAPS - Capsule","Strength":"14","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531780000120","GenericName":"VIMSELTINIB CAP 14 MG","NDC":"73207030240"},{"Id":418031,"FormularyType":"OHP","DrugName":"ROMVIMZA CAP 14MG","DosageForm":"CAPS - Capsule","Strength":"14","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531780000120","GenericName":"VIMSELTINIB CAP 14 MG","NDC":"73207030241"},{"Id":418032,"FormularyType":"OHP","DrugName":"ROMVIMZA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531780000130","GenericName":"VIMSELTINIB CAP 20 MG","NDC":"73207030340"},{"Id":418033,"FormularyType":"OHP","DrugName":"ROMVIMZA CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531780000130","GenericName":"VIMSELTINIB CAP 20 MG","NDC":"73207030341"},{"Id":418034,"FormularyType":"OHP","DrugName":"ROMVIMZA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531780000140","GenericName":"VIMSELTINIB CAP 30 MG","NDC":"73207030440"},{"Id":418035,"FormularyType":"OHP","DrugName":"ROMVIMZA CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531780000140","GenericName":"VIMSELTINIB CAP 30 MG","NDC":"73207030441"},{"Id":418036,"FormularyType":"OHP","DrugName":"ZELVYSIA POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"73289007001"},{"Id":418037,"FormularyType":"OHP","DrugName":"ZELVYSIA POW 100MG","DosageForm":"PACK - Packet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103020","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","NDC":"73289007002"},{"Id":418038,"FormularyType":"OHP","DrugName":"ZELVYSIA POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"73289007101"},{"Id":418039,"FormularyType":"OHP","DrugName":"ZELVYSIA POW 500MG","DosageForm":"PACK - Packet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30908565103040","GenericName":"SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","NDC":"73289007102"},{"Id":418040,"FormularyType":"OHP","DrugName":"ELLA TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"EMERGENCY CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25400070100320","GenericName":"ULIPRISTAL ACETATE TAB 30 MG","NDC":"73302045601"},{"Id":418041,"FormularyType":"OHP","DrugName":"COMFRT TOUCH PAD ALC PREP","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"73317441601"},{"Id":418042,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 33GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317446204"},{"Id":418043,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 33GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317446205"},{"Id":418044,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 33GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317446206"},{"Id":418045,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317446304"},{"Id":418046,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317446305"},{"Id":418047,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317446306"},{"Id":418048,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317446308"},{"Id":418049,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317446504"},{"Id":418050,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317446505"},{"Id":418051,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317446506"},{"Id":418052,"FormularyType":"OHP","DrugName":"COMFORT TOUC MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317446508"},{"Id":418053,"FormularyType":"OHP","DrugName":"HOLDING CHAM MIS CHILD","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"73317495201"},{"Id":418054,"FormularyType":"OHP","DrugName":"HOLDING CHAM MIS ADULT","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"73317495202"},{"Id":418055,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317610904"},{"Id":418056,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317610905"},{"Id":418057,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317610906"},{"Id":418058,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317610908"},{"Id":418059,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317612904"},{"Id":418060,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317612905"},{"Id":418061,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317612906"},{"Id":418062,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317612908"},{"Id":418063,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317623704"},{"Id":418064,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317623705"},{"Id":418065,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317623706"},{"Id":418066,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146380","GenericName":"INSULIN PEN NEEDLE 33 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317623708"},{"Id":418067,"FormularyType":"OHP","DrugName":"AUM READYGRD MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317624501"},{"Id":418068,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"73317628101"},{"Id":418069,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317628204"},{"Id":418070,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317628205"},{"Id":418071,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317628206"},{"Id":418072,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317628304"},{"Id":418073,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317628305"},{"Id":418074,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317628306"},{"Id":418075,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317628504"},{"Id":418076,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317628505"},{"Id":418077,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317628506"},{"Id":418078,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317628508"},{"Id":418079,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317628604"},{"Id":418080,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317628605"},{"Id":418081,"FormularyType":"OHP","DrugName":"AUM MINI PEN MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317628606"},{"Id":418082,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317666604"},{"Id":418083,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317666605"},{"Id":418084,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317678904"},{"Id":418085,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317678905"},{"Id":418086,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317681604"},{"Id":418087,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317681605"},{"Id":418088,"FormularyType":"OHP","DrugName":"AUM SAFETY MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317778904"},{"Id":418089,"FormularyType":"OHP","DrugName":"AUM SAFETY MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317778905"},{"Id":418090,"FormularyType":"OHP","DrugName":"NEONATAL TAB PLUS","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"73317824601"},{"Id":418091,"FormularyType":"OHP","DrugName":"AUM ALCOHOL PAD PREP 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"73317880101"},{"Id":418092,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317960504"},{"Id":418093,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317960505"},{"Id":418094,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317960506"},{"Id":418095,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317960508"},{"Id":418096,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317960604"},{"Id":418097,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317960605"},{"Id":418098,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317960606"},{"Id":418099,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317960608"},{"Id":418100,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"73317960704"},{"Id":418101,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"73317960705"},{"Id":418102,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"73317960706"},{"Id":418103,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 33GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146380","GenericName":"INSULIN PEN NEEDLE 33 G X 8 MM (1/3\" OR 5/16\")","NDC":"73317960708"},{"Id":418104,"FormularyType":"OHP","DrugName":"QUICK TOUCH MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"73317971207"},{"Id":418105,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"73320000102"},{"Id":418106,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"73320000202"},{"Id":418107,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"73320000203"},{"Id":418108,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000305","GenericName":"BACLOFEN TAB 10 MG","NDC":"73320000204"},{"Id":418109,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"73320000302"},{"Id":418110,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"73320000303"},{"Id":418111,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000310","GenericName":"BACLOFEN TAB 20 MG","NDC":"73320000304"},{"Id":418112,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100320","GenericName":"DICYCLOMINE HCL TAB 40 MG","NDC":"73352011960"},{"Id":418113,"FormularyType":"OHP","DrugName":"EVEXITHROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"73352069310"},{"Id":418114,"FormularyType":"OHP","DrugName":"EVEXITHROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"73352069410"},{"Id":418115,"FormularyType":"OHP","DrugName":"EVEXITHROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"73352069610"},{"Id":418116,"FormularyType":"OHP","DrugName":"EVEXITHROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"73352069810"},{"Id":418117,"FormularyType":"OHP","DrugName":"EVEXITHROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"73352069910"},{"Id":418118,"FormularyType":"OHP","DrugName":"EVEXITHROID TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000330","GenericName":"THYROID TAB 180 MG (3 GRAIN)","NDC":"73352070010"},{"Id":418119,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"73473030030"},{"Id":418120,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 2XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104007","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (TWICE-DAILY)","NDC":"73473030060"},{"Id":418121,"FormularyType":"OHP","DrugName":"CLINDAMYCIN GEL 1% 1XDLY","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90051010104006","GenericName":"CLINDAMYCIN PHOSPHATE GEL 1% (ONCE-DAILY)","NDC":"73473030275"},{"Id":418122,"FormularyType":"OHP","DrugName":"METRONIDAZOL GEL 0.75%VAG","DosageForm":"GEL - Gel","Strength":"0.75","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55100035004020","GenericName":"METRONIDAZOLE VAGINAL GEL 0.75%","NDC":"73473030370"},{"Id":418123,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"73473080001"},{"Id":418124,"FormularyType":"OHP","DrugName":"DICYCLOMINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100105","GenericName":"DICYCLOMINE HCL CAP 10 MG","NDC":"73473080010"},{"Id":418125,"FormularyType":"OHP","DrugName":"NEOMYCIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000040100305","GenericName":"NEOMYCIN SULFATE TAB 500 MG","NDC":"73473090105"},{"Id":418126,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"73473090201"},{"Id":418127,"FormularyType":"OHP","DrugName":"DICYCLOMINE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"ANTISPASMODICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49103010100305","GenericName":"DICYCLOMINE HCL TAB 20 MG","NDC":"73473090210"},{"Id":418128,"FormularyType":"OHP","DrugName":"MOXIFLOXACIN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"FLUOROQUINOLONES","DrugSubClass":"FLUOROQUINOLONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"05000037100320","GenericName":"MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","NDC":"73473090330"},{"Id":418129,"FormularyType":"OHP","DrugName":"VYVGART INJ HYTRULO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99399902152020","GenericName":"EFGARTIGIMOD ALF-HYALURONIDASE-QVFC SOL 180-2000 MG-UNIT/ML","NDC":"73475310203"},{"Id":418130,"FormularyType":"OHP","DrugName":"BESREMI SOL 500MCG","DosageForm":"SOSY - Soln Pref Syr","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2170007750E520","GenericName":"ROPEGINTERFERON ALFA-2B-NJFT SOLN PREFILLED SYR 500 MCG/ML","NDC":"73536050001"},{"Id":418131,"FormularyType":"OHP","DrugName":"REVUFORJ TAB 110MG","DosageForm":"TABS - Tablet","Strength":"110","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - MENIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21480070200340","GenericName":"REVUMENIB CITRATE TAB 110 MG","NDC":"73555050100"},{"Id":418132,"FormularyType":"OHP","DrugName":"ZENPEP CAP 10000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006728","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10000-32000-42000 UNIT","NDC":"73562011001"},{"Id":418133,"FormularyType":"OHP","DrugName":"ZENPEP CAP 15000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006747","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 15000-47000-63000 UNIT","NDC":"73562011101"},{"Id":418134,"FormularyType":"OHP","DrugName":"ZENPEP CAP 20000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006751","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 20000-63000-84000 UNIT","NDC":"73562011201"},{"Id":418135,"FormularyType":"OHP","DrugName":"ZENPEP CAP 3000UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006707","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-10000-14000 UNIT","NDC":"73562011301"},{"Id":418136,"FormularyType":"OHP","DrugName":"ZENPEP CAP 40000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006783","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 40000-126000-168000 UNIT","NDC":"73562011401"},{"Id":418137,"FormularyType":"OHP","DrugName":"ZENPEP CAP 5000UNIT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006714","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 5000-17000-24000 UNIT","NDC":"73562011501"},{"Id":418138,"FormularyType":"OHP","DrugName":"ZENPEP CAP 25000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006772","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 25000-79000-105000 UNIT","NDC":"73562011601"},{"Id":418139,"FormularyType":"OHP","DrugName":"ZENPEP CAP 60000UNT","DosageForm":"CPEP - Capsule DR Part","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIGESTIVE AIDS","DrugSubClass":"DIGESTIVE ENZYMES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"51200024006795","GenericName":"PANCRELIPASE (LIP-PROT-AMYL) DR CAP 60000-189600-252600 UNIT","NDC":"73562011701"},{"Id":418140,"FormularyType":"OHP","DrugName":"MAXPRO-18G LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"73564080530"},{"Id":418141,"FormularyType":"OHP","DrugName":"CAMZYOS CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIAC MYOSIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40190050000110","GenericName":"MAVACAMTEN CAP 2.5 MG","NDC":"73625011111"},{"Id":418142,"FormularyType":"OHP","DrugName":"CAMZYOS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIAC MYOSIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40190050000120","GenericName":"MAVACAMTEN CAP 5 MG","NDC":"73625011211"},{"Id":418143,"FormularyType":"OHP","DrugName":"CAMZYOS CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIAC MYOSIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40190050000130","GenericName":"MAVACAMTEN CAP 10 MG","NDC":"73625011311"},{"Id":418144,"FormularyType":"OHP","DrugName":"CAMZYOS CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIAC MYOSIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40190050000140","GenericName":"MAVACAMTEN CAP 15 MG","NDC":"73625011411"},{"Id":418145,"FormularyType":"OHP","DrugName":"HYFTOR GEL 0.2%","DosageForm":"GEL - Gel","Strength":"0.2","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90784070004020","GenericName":"SIROLIMUS GEL 0.2%","NDC":"73683010110"},{"Id":418146,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 1GM/10ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"1","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E520","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 1 GM/10ML","NDC":"73702013110"},{"Id":418147,"FormularyType":"OHP","DrugName":"CEFAZOLIN INJ 2GM/20ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"N","DrugCategory":"CEPHALOSPORINS","DrugSubClass":"CEPHALOSPORINS - 1ST GENERATION","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"0210001510E530","GenericName":"CEFAZOLIN SODIUM IV SOLN PREF SYRINGE 2 GM/20ML","NDC":"73702013223"},{"Id":418148,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"73715000401"},{"Id":418149,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"73750009105"},{"Id":418150,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"73750009110"},{"Id":418151,"FormularyType":"OHP","DrugName":"PEAK A-I-R MIS FLW METR","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"73796066940"},{"Id":418152,"FormularyType":"OHP","DrugName":"PEAK AIR FLO MIS ADLT/PED","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97101530006200","GenericName":"PEAK FLOW METER","NDC":"73796069940"},{"Id":418153,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"74012067713"},{"Id":418154,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"74012067714"},{"Id":418155,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"74012067715"},{"Id":418156,"FormularyType":"OHP","DrugName":"SPEEDY SWAB KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"74012067716"},{"Id":418157,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"74312000650"},{"Id":418158,"FormularyType":"OHP","DrugName":"POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"74312001110"},{"Id":418159,"FormularyType":"OHP","DrugName":"SLEEP GUMMIE CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"74312001123"},{"Id":418160,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"74312001380"},{"Id":418161,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"74312002832"},{"Id":418162,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"74312002843"},{"Id":418163,"FormularyType":"OHP","DrugName":"B-12 SUB 500MCG","DosageForm":"SUBL - Tab Sublingual","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000703","GenericName":"CYANOCOBALAMIN SL TAB 500 MCG","NDC":"74312003595"},{"Id":418164,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"74312003822"},{"Id":418165,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"74312003849"},{"Id":418166,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"74312003925"},{"Id":418167,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"74312005535"},{"Id":418168,"FormularyType":"OHP","DrugName":"NIACIN CAP 250MG TR","DosageForm":"CPCR - Capsule ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000210","GenericName":"NIACIN CAP ER 250 MG","NDC":"74312005800"},{"Id":418169,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"74312007087"},{"Id":418170,"FormularyType":"OHP","DrugName":"MELATONIN SUB 3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000725","GenericName":"MELATONIN SL TAB 3 MG","NDC":"74312007901"},{"Id":418171,"FormularyType":"OHP","DrugName":"MELATONIN SUB 3MG","DosageForm":"SUBL - Tab Sublingual","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000725","GenericName":"MELATONIN SL TAB 3 MG","NDC":"74312007903"},{"Id":418172,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312013102"},{"Id":418173,"FormularyType":"OHP","DrugName":"SUPER B-COMP TAB /FA/VITC","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000300","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB***","NDC":"74312013168"},{"Id":418174,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312013329"},{"Id":418175,"FormularyType":"OHP","DrugName":"CALCIUM 600 TAB VIT D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640349","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-3.125 MCG (125 UNIT)","NDC":"74312014230"},{"Id":418176,"FormularyType":"OHP","DrugName":"D3-1000 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"74312015605"},{"Id":418177,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"74312015606"},{"Id":418178,"FormularyType":"OHP","DrugName":"MELATONIN CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000150","GenericName":"MELATONIN CAP 5 MG","NDC":"74312015745"},{"Id":418179,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312016878"},{"Id":418180,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312016887"},{"Id":418181,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312017130"},{"Id":418182,"FormularyType":"OHP","DrugName":"D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"74312017621"},{"Id":418183,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"74312019377"},{"Id":418184,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"74312019491"},{"Id":418185,"FormularyType":"OHP","DrugName":"D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"74312019939"},{"Id":418186,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312027602"},{"Id":418187,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"74312027800"},{"Id":418188,"FormularyType":"OHP","DrugName":"D3 MAXIMUM CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"74312029176"},{"Id":418189,"FormularyType":"OHP","DrugName":"D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"74312030413"},{"Id":418190,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312030697"},{"Id":418191,"FormularyType":"OHP","DrugName":"D3 SUPER STR CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"74312030698"},{"Id":418192,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"74312031499"},{"Id":418193,"FormularyType":"OHP","DrugName":"D3 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"74312035873"},{"Id":418194,"FormularyType":"OHP","DrugName":"IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"74312041383"},{"Id":418195,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"74312052802"},{"Id":418196,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"74312052805"},{"Id":418197,"FormularyType":"OHP","DrugName":"D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"74312052807"},{"Id":418198,"FormularyType":"OHP","DrugName":"MAGNESIUM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360340","GenericName":"MAGNESIUM OXIDE TAB 500 MG (MG SUPPLEMENT)","NDC":"74312053086"},{"Id":418199,"FormularyType":"OHP","DrugName":"D3 CHW 50MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"74312067291"},{"Id":418200,"FormularyType":"OHP","DrugName":"YL VIT B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"74970005285"},{"Id":418201,"FormularyType":"OHP","DrugName":"YL FOLIC ACI TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"74970005500"},{"Id":418202,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"75450006454"},{"Id":418203,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"75450028961"},{"Id":418204,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"75450029485"},{"Id":418205,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"75450029539"},{"Id":418206,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"75450029544"},{"Id":418207,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"75450029576"},{"Id":418208,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"75450029758"},{"Id":418209,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"75450031099"},{"Id":418210,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"75450031199"},{"Id":418211,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"75450031287"},{"Id":418212,"FormularyType":"OHP","DrugName":"GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"75450031297"},{"Id":418213,"FormularyType":"OHP","DrugName":"GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"75450031397"},{"Id":418214,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"75826010700"},{"Id":418215,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"75826010703"},{"Id":418216,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"75826010790"},{"Id":418217,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100305","GenericName":"PHENAZOPYRIDINE HCL TAB 100 MG","NDC":"75826011410"},{"Id":418218,"FormularyType":"OHP","DrugName":"PHENAZOPYRID TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"URINARY ANALGESICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56300010100310","GenericName":"PHENAZOPYRIDINE HCL TAB 200 MG","NDC":"75826011510"},{"Id":418219,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100303","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 2.5 MG","NDC":"75826012010"},{"Id":418220,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100303","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 2.5 MG","NDC":"75826012030"},{"Id":418221,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100308","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 7.5 MG","NDC":"75826012210"},{"Id":418222,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100308","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 7.5 MG","NDC":"75826012230"},{"Id":418223,"FormularyType":"OHP","DrugName":"DEXTROAMPHET TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"AMPHETAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61100020100310","GenericName":"DEXTROAMPHETAMINE SULFATE TAB 10 MG","NDC":"75826012310"},{"Id":418224,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"75826012905"},{"Id":418225,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 10MG/5ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102065","GenericName":"MORPHINE SULFATE ORAL SOLN 10 MG/5ML","NDC":"75826012917"},{"Id":418226,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 20MG/5ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102070","GenericName":"MORPHINE SULFATE ORAL SOLN 20 MG/5ML","NDC":"75826013005"},{"Id":418227,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 20MG/5ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102070","GenericName":"MORPHINE SULFATE ORAL SOLN 20 MG/5ML","NDC":"75826013017"},{"Id":418228,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"75826013101"},{"Id":418229,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"75826013104"},{"Id":418230,"FormularyType":"OHP","DrugName":"MORPHINE SUL SOL 100/5ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102090","GenericName":"MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","NDC":"75826013115"},{"Id":418231,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"75826013610"},{"Id":418232,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000305","GenericName":"PHENOBARBITAL TAB 15 MG","NDC":"75826013650"},{"Id":418233,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"75826013700"},{"Id":418234,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 16.2MG","DosageForm":"TABS - Tablet","Strength":"16.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000308","GenericName":"PHENOBARBITAL TAB 16.2 MG","NDC":"75826013710"},{"Id":418235,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"75826013810"},{"Id":418236,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000315","GenericName":"PHENOBARBITAL TAB 30 MG","NDC":"75826013850"},{"Id":418237,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"75826013900"},{"Id":418238,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 32.4MG","DosageForm":"TABS - Tablet","Strength":"32.4","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000317","GenericName":"PHENOBARBITAL TAB 32.4 MG","NDC":"75826013910"},{"Id":418239,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"75826014010"},{"Id":418240,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000320","GenericName":"PHENOBARBITAL TAB 60 MG","NDC":"75826014050"},{"Id":418241,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"75826014100"},{"Id":418242,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 64.8MG","DosageForm":"TABS - Tablet","Strength":"64.8","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000322","GenericName":"PHENOBARBITAL TAB 64.8 MG","NDC":"75826014110"},{"Id":418243,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"75826014200"},{"Id":418244,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 97.2MG","DosageForm":"TABS - Tablet","Strength":"97.2","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000324","GenericName":"PHENOBARBITAL TAB 97.2 MG","NDC":"75826014210"},{"Id":418245,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"75826014310"},{"Id":418246,"FormularyType":"OHP","DrugName":"PHENOBARB TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060000325","GenericName":"PHENOBARBITAL TAB 100 MG","NDC":"75826014350"},{"Id":418247,"FormularyType":"OHP","DrugName":"FLUORIDE CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0.25","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000505","GenericName":"SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)","NDC":"75826016320"},{"Id":418248,"FormularyType":"OHP","DrugName":"FLUORIDE CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0.5","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000510","GenericName":"SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)","NDC":"75826016420"},{"Id":418249,"FormularyType":"OHP","DrugName":"FLUORIDE CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"FLUORIDE","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"79300020000515","GenericName":"SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","NDC":"75826016520"},{"Id":418250,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000505","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***","NDC":"75826016910"},{"Id":418251,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 0.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000510","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***","NDC":"75826017010"},{"Id":418252,"FormularyType":"OHP","DrugName":"MULTIVIT/FL CHW 1MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ FLUORIDE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78441000000520","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","NDC":"75826017110"},{"Id":418253,"FormularyType":"OHP","DrugName":"ERGOCALCIFER SOL 8000/ML","DosageForm":"SOLN - Solution","Strength":"8000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202030002030","GenericName":"ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML)","NDC":"75834001060"},{"Id":418254,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"75834002001"},{"Id":418255,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"50000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"75834002012"},{"Id":418256,"FormularyType":"OHP","DrugName":"NIVA-PLUS TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"75834005001"},{"Id":418257,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"75834010901"},{"Id":418258,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000305","GenericName":"CHLORTHALIDONE TAB 25 MG","NDC":"75834010910"},{"Id":418259,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"75834011001"},{"Id":418260,"FormularyType":"OHP","DrugName":"CHLORTHALID TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600025000310","GenericName":"CHLORTHALIDONE TAB 50 MG","NDC":"75834011010"},{"Id":418261,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"75834011529"},{"Id":418262,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.03MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150320","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","NDC":"75834011584"},{"Id":418263,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"75834011629"},{"Id":418264,"FormularyType":"OHP","DrugName":"DROSPIR/ETHI TAB 3-0.02MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002150316","GenericName":"DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","NDC":"75834011684"},{"Id":418265,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"75834012201"},{"Id":418266,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"75834012205"},{"Id":418267,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"75834012301"},{"Id":418268,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"75834012305"},{"Id":418269,"FormularyType":"OHP","DrugName":"ACYCLOVIR CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000110","GenericName":"ACYCLOVIR CAP 200 MG","NDC":"75834012401"},{"Id":418270,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"75834012601"},{"Id":418271,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"75834012700"},{"Id":418272,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"75834012701"},{"Id":418273,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"75834012801"},{"Id":418274,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"75834013105"},{"Id":418275,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"75834013118"},{"Id":418276,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"75834013160"},{"Id":418277,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"75834013205"},{"Id":418278,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000110","GenericName":"TEMOZOLOMIDE CAP 5 MG","NDC":"75834013214"},{"Id":418279,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"75834013305"},{"Id":418280,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 1.5MG","DosageForm":"CAPS - Capsule","Strength":"1.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200110","GenericName":"RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","NDC":"75834013360"},{"Id":418281,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"75834013405"},{"Id":418282,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 3MG","DosageForm":"CAPS - Capsule","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200120","GenericName":"RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","NDC":"75834013460"},{"Id":418283,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"75834013505"},{"Id":418284,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 4.5MG","DosageForm":"CAPS - Capsule","Strength":"4.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200130","GenericName":"RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","NDC":"75834013560"},{"Id":418285,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"75834013605"},{"Id":418286,"FormularyType":"OHP","DrugName":"RIVASTIGMINE CAP 6MG","DosageForm":"CAPS - Capsule","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051040200140","GenericName":"RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","NDC":"75834013660"},{"Id":418287,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"75834014205"},{"Id":418288,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000120","GenericName":"TEMOZOLOMIDE CAP 20 MG","NDC":"75834014214"},{"Id":418289,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"75834014305"},{"Id":418290,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000140","GenericName":"TEMOZOLOMIDE CAP 100 MG","NDC":"75834014314"},{"Id":418291,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"75834014405"},{"Id":418292,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 140MG","DosageForm":"CAPS - Capsule","Strength":"140","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000143","GenericName":"TEMOZOLOMIDE CAP 140 MG","NDC":"75834014414"},{"Id":418293,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"75834014505"},{"Id":418294,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 180MG","DosageForm":"CAPS - Capsule","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000147","GenericName":"TEMOZOLOMIDE CAP 180 MG","NDC":"75834014514"},{"Id":418295,"FormularyType":"OHP","DrugName":"TEMOZOLOMIDE CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21104070000150","GenericName":"TEMOZOLOMIDE CAP 250 MG","NDC":"75834014605"},{"Id":418296,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 180MG ER","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100415","GenericName":"VERAPAMIL HCL TAB ER 180 MG","NDC":"75834015801"},{"Id":418297,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 180MG ER","DosageForm":"TBCR - Tablet ER","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100415","GenericName":"VERAPAMIL HCL TAB ER 180 MG","NDC":"75834015805"},{"Id":418298,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 240MG ER","DosageForm":"TBCR - Tablet ER","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100420","GenericName":"VERAPAMIL HCL TAB ER 240 MG","NDC":"75834015901"},{"Id":418299,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 240MG ER","DosageForm":"TBCR - Tablet ER","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100420","GenericName":"VERAPAMIL HCL TAB ER 240 MG","NDC":"75834015905"},{"Id":418300,"FormularyType":"OHP","DrugName":"WEEKLY-D CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"75834016712"},{"Id":418301,"FormularyType":"OHP","DrugName":"WEEKLY-D CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"75834016724"},{"Id":418302,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"75834017001"},{"Id":418303,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"75834017002"},{"Id":418304,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"75834017015"},{"Id":418305,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000320","GenericName":"NATEGLINIDE TAB 60 MG","NDC":"75834020501"},{"Id":418306,"FormularyType":"OHP","DrugName":"NATEGLINIDE TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"MEGLITINIDE ANALOGUES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27280040000330","GenericName":"NATEGLINIDE TAB 120 MG","NDC":"75834020601"},{"Id":418307,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"75834022100"},{"Id":418308,"FormularyType":"OHP","DrugName":"CARBAMAZEPIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600020000305","GenericName":"CARBAMAZEPINE TAB 200 MG","NDC":"75834022101"},{"Id":418309,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"75834023516"},{"Id":418310,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"75834023560"},{"Id":418311,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"75834023701"},{"Id":418312,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"75834023705"},{"Id":418313,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"75834023801"},{"Id":418314,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"75834023805"},{"Id":418315,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"75834025501"},{"Id":418316,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"75834025550"},{"Id":418317,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"75834025590"},{"Id":418318,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"75834025601"},{"Id":418319,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"75834025650"},{"Id":418320,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"75834025690"},{"Id":418321,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"75834025701"},{"Id":418322,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"75834025750"},{"Id":418323,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"75834025790"},{"Id":418324,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"75834025801"},{"Id":418325,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"75834025850"},{"Id":418326,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"75834025890"},{"Id":418327,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100305","GenericName":"ALBUTEROL SULFATE TAB 2 MG","NDC":"75834027301"},{"Id":418328,"FormularyType":"OHP","DrugName":"ALBUTEROL TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010100310","GenericName":"ALBUTEROL SULFATE TAB 4 MG","NDC":"75834027401"},{"Id":418329,"FormularyType":"OHP","DrugName":"POT IODIDE SOL 1GM/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"EXPECTORANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43202010002060","GenericName":"POTASSIUM IODIDE ORAL SOLN 1 GM/ML","NDC":"75834028008"},{"Id":418330,"FormularyType":"OHP","DrugName":"POT IODIDE SOL 1GM/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"EXPECTORANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43202010002060","GenericName":"POTASSIUM IODIDE ORAL SOLN 1 GM/ML","NDC":"75834028030"},{"Id":418331,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000303","GenericName":"ATENOLOL TAB 25 MG","NDC":"75834028100"},{"Id":418332,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000305","GenericName":"ATENOLOL TAB 50 MG","NDC":"75834028200"},{"Id":418333,"FormularyType":"OHP","DrugName":"ATENOLOL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200020000310","GenericName":"ATENOLOL TAB 100 MG","NDC":"75834028300"},{"Id":418334,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"75834029000"},{"Id":418335,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"75834029001"},{"Id":418336,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"75834029005"},{"Id":418337,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"75834029100"},{"Id":418338,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"75834029101"},{"Id":418339,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"75834029105"},{"Id":418340,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"75834029200"},{"Id":418341,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"75834029201"},{"Id":418342,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"75834029205"},{"Id":418343,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"75834029300"},{"Id":418344,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"75834029301"},{"Id":418345,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"75834029305"},{"Id":418346,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"75834030090"},{"Id":418347,"FormularyType":"OHP","DrugName":"NIVA THYROID TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000305","GenericName":"THYROID TAB 15 MG (1/4 GRAIN)","NDC":"75834031001"},{"Id":418348,"FormularyType":"OHP","DrugName":"NIVA THYROID TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000310","GenericName":"THYROID TAB 30 MG (1/2 GRAIN)","NDC":"75834031101"},{"Id":418349,"FormularyType":"OHP","DrugName":"NIVA THYROID TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000315","GenericName":"THYROID TAB 60 MG (1 GRAIN)","NDC":"75834031201"},{"Id":418350,"FormularyType":"OHP","DrugName":"NIVA THYROID TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000320","GenericName":"THYROID TAB 90 MG (1 1/2 GRAIN)","NDC":"75834031301"},{"Id":418351,"FormularyType":"OHP","DrugName":"NIVA THYROID TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"N","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100050000325","GenericName":"THYROID TAB 120 MG (2 GRAIN)","NDC":"75834031401"},{"Id":418352,"FormularyType":"OHP","DrugName":"VERAPAMIL TAB 120MG ER","DosageForm":"TBCR - Tablet ER","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000030100410","GenericName":"VERAPAMIL HCL TAB ER 120 MG","NDC":"75834032001"},{"Id":418353,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"75834032302"},{"Id":418354,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100305","GenericName":"METHYLPHENIDATE HCL TAB 5 MG","NDC":"75834032401"},{"Id":418355,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100310","GenericName":"METHYLPHENIDATE HCL TAB 10 MG","NDC":"75834032501"},{"Id":418356,"FormularyType":"OHP","DrugName":"METHYLPHENID TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400020100315","GenericName":"METHYLPHENIDATE HCL TAB 20 MG","NDC":"75834032601"},{"Id":418357,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100330","GenericName":"DEXMETHYLPHENIDATE HCL TAB 5 MG","NDC":"75834032701"},{"Id":418358,"FormularyType":"OHP","DrugName":"DEXMETHYLPH TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS","DrugSubClass":"STIMULANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"61400016100340","GenericName":"DEXMETHYLPHENIDATE HCL TAB 10 MG","NDC":"75834032801"},{"Id":418359,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100310","GenericName":"LIOTHYRONINE SODIUM TAB 25 MCG","NDC":"75907000101"},{"Id":418360,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100315","GenericName":"LIOTHYRONINE SODIUM TAB 50 MCG","NDC":"75907000401"},{"Id":418361,"FormularyType":"OHP","DrugName":"AMIODARONE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400005000305","GenericName":"AMIODARONE HCL TAB 200 MG","NDC":"75907000660"},{"Id":418362,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"75907002001"},{"Id":418363,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"75907002005"},{"Id":418364,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100320","GenericName":"CARBIDOPA & LEVODOPA TAB 25-100 MG","NDC":"75907002010"},{"Id":418365,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"75907002101"},{"Id":418366,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 25-250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100330","GenericName":"CARBIDOPA & LEVODOPA TAB 25-250 MG","NDC":"75907002105"},{"Id":418367,"FormularyType":"OHP","DrugName":"CARB/LEVO TAB 10-100MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100310","GenericName":"CARBIDOPA & LEVODOPA TAB 10-100 MG","NDC":"75907002201"},{"Id":418368,"FormularyType":"OHP","DrugName":"DISOPYRAMIDE CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010100110","GenericName":"DISOPYRAMIDE PHOSPHATE CAP 150 MG","NDC":"75907002601"},{"Id":418369,"FormularyType":"OHP","DrugName":"DISOPYRAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100010100105","GenericName":"DISOPYRAMIDE PHOSPHATE CAP 100 MG","NDC":"75907002701"},{"Id":418370,"FormularyType":"OHP","DrugName":"LIOTHYRONINE TAB 5MCG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"THYROID AGENTS","DrugSubClass":"THYROID HORMONES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"28100020100305","GenericName":"LIOTHYRONINE SODIUM TAB 5 MCG","NDC":"75907003901"},{"Id":418371,"FormularyType":"OHP","DrugName":"TRIMETHOPRIM TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"O","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"ANTI-INFECTIVE AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16000055000305","GenericName":"TRIMETHOPRIM TAB 100 MG","NDC":"75907004301"},{"Id":418372,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 60MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106910","GenericName":"DILTIAZEM HCL CAP ER 12HR 60 MG","NDC":"75907004401"},{"Id":418373,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 90MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106915","GenericName":"DILTIAZEM HCL CAP ER 12HR 90 MG","NDC":"75907004501"},{"Id":418374,"FormularyType":"OHP","DrugName":"DILTIAZEM CAP 120MG ER","DosageForm":"CP12 - Capsule ER 12 HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000010106920","GenericName":"DILTIAZEM HCL CAP ER 12HR 120 MG","NDC":"75907004601"},{"Id":418375,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"75907004730"},{"Id":418376,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 25MG MOD","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300120","GenericName":"CYCLOSPORINE MODIFIED CAP 25 MG","NDC":"75907004781"},{"Id":418377,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"75907004830"},{"Id":418378,"FormularyType":"OHP","DrugName":"CYCLOSPORINE CAP 100MG MD","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99402020300150","GenericName":"CYCLOSPORINE MODIFIED CAP 100 MG","NDC":"75907004881"},{"Id":418379,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"75907005460"},{"Id":418380,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"75907005560"},{"Id":418381,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"75907005660"},{"Id":418382,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100310","GenericName":"TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"75907005810"},{"Id":418383,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100310","GenericName":"TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","NDC":"75907005860"},{"Id":418384,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"75907005910"},{"Id":418385,"FormularyType":"OHP","DrugName":"TAMOXIFEN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402680100320","GenericName":"TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","NDC":"75907005930"},{"Id":418386,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"75907006030"},{"Id":418387,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"75907006044"},{"Id":418388,"FormularyType":"OHP","DrugName":"NYSTATIN POW 100000","DosageForm":"POWD - Powder","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150080002920","GenericName":"NYSTATIN TOPICAL POWDER 100000 UNIT/GM","NDC":"75907006060"},{"Id":418389,"FormularyType":"OHP","DrugName":"CAMILA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"75907007428"},{"Id":418390,"FormularyType":"OHP","DrugName":"CAMILA TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"75907007432"},{"Id":418391,"FormularyType":"OHP","DrugName":"ERRIN TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"75907007528"},{"Id":418392,"FormularyType":"OHP","DrugName":"ERRIN TAB 0.35MG","DosageForm":"TABS - Tablet","Strength":"0.35","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"PROGESTIN CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25100010000305","GenericName":"NORETHINDRONE TAB 0.35 MG","NDC":"75907007532"},{"Id":418393,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB FE1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"75907008128"},{"Id":418394,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB FE1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","NDC":"75907008162"},{"Id":418395,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"75907008228"},{"Id":418396,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB FE 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990003610310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","NDC":"75907008262"},{"Id":418397,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"75907008321"},{"Id":418398,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB 1.5/30","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600320","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","NDC":"75907008363"},{"Id":418399,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"75907008421"},{"Id":418400,"FormularyType":"OHP","DrugName":"MICROGESTIN TAB 1/20","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002600310","GenericName":"NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","NDC":"75907008463"},{"Id":418401,"FormularyType":"OHP","DrugName":"NECON TAB 0.5/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500310","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","NDC":"75907008528"},{"Id":418402,"FormularyType":"OHP","DrugName":"NECON TAB 0.5/35","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002500310","GenericName":"NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","NDC":"75907008532"},{"Id":418403,"FormularyType":"OHP","DrugName":"TILIA FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992003300340","GenericName":"NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG","NDC":"75907008628"},{"Id":418404,"FormularyType":"OHP","DrugName":"TILIA FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25992003300340","GenericName":"NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG","NDC":"75907008632"},{"Id":418405,"FormularyType":"OHP","DrugName":"ZOVIA 1/35 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25990002200310","GenericName":"ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","NDC":"75907008762"},{"Id":418406,"FormularyType":"OHP","DrugName":"AZURETTE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"75907009128"},{"Id":418407,"FormularyType":"OHP","DrugName":"AZURETTE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CONTRACEPTIVES","DrugSubClass":"COMBINATION CONTRACEPTIVES - ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"25991002050320","GenericName":"DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","NDC":"75907009162"},{"Id":418408,"FormularyType":"OHP","DrugName":"FLUOROURACIL CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90372030003730","GenericName":"FLUOROURACIL CREAM 5%","NDC":"75907009540"},{"Id":418409,"FormularyType":"OHP","DrugName":"IVERMECTIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000007000310","GenericName":"IVERMECTIN TAB 3 MG","NDC":"75907016710"},{"Id":418410,"FormularyType":"OHP","DrugName":"IVERMECTIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000007000310","GenericName":"IVERMECTIN TAB 3 MG","NDC":"75907016721"},{"Id":418411,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"75907022404"},{"Id":418412,"FormularyType":"OHP","DrugName":"TRANEX ACID TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"HEMOSTATICS","DrugSubClass":"HEMOSTATICS - SYSTEMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"84100040000320","GenericName":"TRANEXAMIC ACID TAB 650 MG","NDC":"75907030930"},{"Id":418413,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"75907034401"},{"Id":418414,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"75907034410"},{"Id":418415,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"75907034501"},{"Id":418416,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"75907034510"},{"Id":418417,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"75907034601"},{"Id":418418,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"75907034605"},{"Id":418419,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"75907034701"},{"Id":418420,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"75907034710"},{"Id":418421,"FormularyType":"OHP","DrugName":"ACTIMMUNE INJ 2MU/0.5","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700060702020","GenericName":"INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML)","NDC":"75987011110"},{"Id":418422,"FormularyType":"OHP","DrugName":"ACTIMMUNE INJ 2MU/0.5","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTICS MISC.","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21700060702020","GenericName":"INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML)","NDC":"75987011111"},{"Id":418423,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"76000018065"},{"Id":418424,"FormularyType":"OHP","DrugName":"MIDAZOLAM INJ 5MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"NON-BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60201025102006","GenericName":"MIDAZOLAM HCL INJ PF 5 MG/ML (BASE EQUIVALENT)","NDC":"76045000210"},{"Id":418425,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102005","GenericName":"MORPHINE SULFATE INJ 2 MG/ML","NDC":"76045000401"},{"Id":418426,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102005","GenericName":"MORPHINE SULFATE INJ 2 MG/ML","NDC":"76045000411"},{"Id":418427,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102010","GenericName":"MORPHINE SULFATE INJ 4 MG/ML","NDC":"76045000501"},{"Id":418428,"FormularyType":"OHP","DrugName":"MORPHINE SUL INJ 4MG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102010","GenericName":"MORPHINE SULFATE INJ 4 MG/ML","NDC":"76045000511"},{"Id":418429,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"76045010120"},{"Id":418430,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"76045010200"},{"Id":418431,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"76045010210"},{"Id":418432,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"76045010800"},{"Id":418433,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"76045010810"},{"Id":418434,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"76045011201"},{"Id":418435,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 2MG/2ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"76045011220"},{"Id":418436,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 0.4MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E510","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 0.4 MG/ML","NDC":"76045011401"},{"Id":418437,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 0.4MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E510","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 0.4 MG/ML","NDC":"76045011410"},{"Id":418438,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"76045021300"},{"Id":418439,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"76045021320"},{"Id":418440,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"76077040004"},{"Id":418441,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"76077040007"},{"Id":418442,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"76204001001"},{"Id":418443,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.63MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"0.63","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102555","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","NDC":"76204001055"},{"Id":418444,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"76204001101"},{"Id":418445,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 1.25MG/3","DosageForm":"NEBU - Nebulization solution","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102560","GenericName":"ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","NDC":"76204001155"},{"Id":418446,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"76204001801"},{"Id":418447,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 7%","DosageForm":"NEBU - Nebulization solution","Strength":"7","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002535","GenericName":"SODIUM CHLORIDE SOLN NEBU 7%","NDC":"76204002160"},{"Id":418448,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 3%","DosageForm":"NEBU - Nebulization solution","Strength":"3","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002530","GenericName":"SODIUM CHLORIDE SOLN NEBU 3%","NDC":"76204002260"},{"Id":418449,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.5%","DosageForm":"NEBU - Nebulization solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102520","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)","NDC":"76204002701"},{"Id":418450,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.5%","DosageForm":"NEBU - Nebulization solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102520","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)","NDC":"76204002711"},{"Id":418451,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"76204002904"},{"Id":418452,"FormularyType":"OHP","DrugName":"TOBRAMYCIN NEB 300/5ML","DosageForm":"NEBU - Nebulization solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000070002520","GenericName":"TOBRAMYCIN NEBU SOLN 300 MG/5ML","NDC":"76204002956"},{"Id":418453,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"76204010001"},{"Id":418454,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"76204010025"},{"Id":418455,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"76204010030"},{"Id":418456,"FormularyType":"OHP","DrugName":"IPRATROPIUM SOL 0.02%INH","DosageForm":"SOLN - Solution","Strength":"0.02","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"BRONCHODILATORS - ANTICHOLINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44100030102020","GenericName":"IPRATROPIUM BROMIDE INHAL SOLN 0.02%","NDC":"76204010060"},{"Id":418457,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"76204020001"},{"Id":418458,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"76204020025"},{"Id":418459,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"76204020030"},{"Id":418460,"FormularyType":"OHP","DrugName":"ALBUTEROL NEB 0.083%","DosageForm":"NEBU - Nebulization solution","Strength":"0.083","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010102515","GenericName":"ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","NDC":"76204020060"},{"Id":418461,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"76204030003"},{"Id":418462,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"76204030005"},{"Id":418463,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 0.9%","DosageForm":"NEBU - Nebulization solution","Strength":"0.9","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002520","GenericName":"SODIUM CHLORIDE SOLN NEBU 0.9%","NDC":"76204030050"},{"Id":418464,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"76204060001"},{"Id":418465,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"76204060005"},{"Id":418466,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"76204060012"},{"Id":418467,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"76204060030"},{"Id":418468,"FormularyType":"OHP","DrugName":"IPRATROPIUM/ SOL ALBUTER","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44209902012015","GenericName":"IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","NDC":"76204060060"},{"Id":418469,"FormularyType":"OHP","DrugName":"DICLOFENAC GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"76282010339"},{"Id":418470,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"76282015201"},{"Id":418471,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"76282015210"},{"Id":418472,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"76282015301"},{"Id":418473,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"76282015310"},{"Id":418474,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"76282020010"},{"Id":418475,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100310","GenericName":"FOSINOPRIL SODIUM TAB 10 MG","NDC":"76282020090"},{"Id":418476,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"76282020110"},{"Id":418477,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100320","GenericName":"FOSINOPRIL SODIUM TAB 20 MG","NDC":"76282020190"},{"Id":418478,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"76282020210"},{"Id":418479,"FormularyType":"OHP","DrugName":"FOSINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100027100340","GenericName":"FOSINOPRIL SODIUM TAB 40 MG","NDC":"76282020290"},{"Id":418480,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"76282022505"},{"Id":418481,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"76282022518"},{"Id":418482,"FormularyType":"OHP","DrugName":"GEMFIBROZIL TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200030000310","GenericName":"GEMFIBROZIL TAB 600 MG","NDC":"76282022560"},{"Id":418483,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000105","GenericName":"ZONISAMIDE CAP 25 MG","NDC":"76282022601"},{"Id":418484,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000110","GenericName":"ZONISAMIDE CAP 50 MG","NDC":"76282022701"},{"Id":418485,"FormularyType":"OHP","DrugName":"ZONISAMIDE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600090000120","GenericName":"ZONISAMIDE CAP 100 MG","NDC":"76282022801"},{"Id":418486,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"76282023710"},{"Id":418487,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"76282023790"},{"Id":418488,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"76282025605"},{"Id":418489,"FormularyType":"OHP","DrugName":"RALOXIFENE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"HORMONE RECEPTOR MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30053060100320","GenericName":"RALOXIFENE HCL TAB 60 MG","NDC":"76282025630"},{"Id":418490,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"76282025701"},{"Id":418491,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000320","GenericName":"NABUMETONE TAB 500 MG","NDC":"76282025705"},{"Id":418492,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"76282025801"},{"Id":418493,"FormularyType":"OHP","DrugName":"NABUMETONE TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100055000330","GenericName":"NABUMETONE TAB 750 MG","NDC":"76282025805"},{"Id":418494,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"76282027810"},{"Id":418495,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"76282027860"},{"Id":418496,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"76282027910"},{"Id":418497,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"76282027960"},{"Id":418498,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"76282028010"},{"Id":418499,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"76282028060"},{"Id":418500,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"76282028110"},{"Id":418501,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000340","GenericName":"TOPIRAMATE TAB 200 MG","NDC":"76282028160"},{"Id":418502,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"76282028310"},{"Id":418503,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"76282028318"},{"Id":418504,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"76282028327"},{"Id":418505,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"76282028330"},{"Id":418506,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"76282028360"},{"Id":418507,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"76282028390"},{"Id":418508,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"76282030201"},{"Id":418509,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"76282030205"},{"Id":418510,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"76282030210"},{"Id":418511,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"76282030212"},{"Id":418512,"FormularyType":"OHP","DrugName":"ALFUZOSIN TAB 10MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852010107530","GenericName":"ALFUZOSIN HCL TAB ER 24HR 10 MG","NDC":"76282030290"},{"Id":418513,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"76282030901"},{"Id":418514,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"76282030910"},{"Id":418515,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"76282031001"},{"Id":418516,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"76282031010"},{"Id":418517,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"76282031101"},{"Id":418518,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"76282031110"},{"Id":418519,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"76282031201"},{"Id":418520,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"76282032105"},{"Id":418521,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"76282032305"},{"Id":418522,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"76282032701"},{"Id":418523,"FormularyType":"OHP","DrugName":"WARFARIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200303","GenericName":"WARFARIN SODIUM TAB 1 MG","NDC":"76282032710"},{"Id":418524,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"76282032801"},{"Id":418525,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200305","GenericName":"WARFARIN SODIUM TAB 2 MG","NDC":"76282032810"},{"Id":418526,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"76282032901"},{"Id":418527,"FormularyType":"OHP","DrugName":"WARFARIN TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200310","GenericName":"WARFARIN SODIUM TAB 2.5 MG","NDC":"76282032910"},{"Id":418528,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"76282033001"},{"Id":418529,"FormularyType":"OHP","DrugName":"WARFARIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200311","GenericName":"WARFARIN SODIUM TAB 3 MG","NDC":"76282033010"},{"Id":418530,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"76282033101"},{"Id":418531,"FormularyType":"OHP","DrugName":"WARFARIN TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200313","GenericName":"WARFARIN SODIUM TAB 4 MG","NDC":"76282033110"},{"Id":418532,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"76282033201"},{"Id":418533,"FormularyType":"OHP","DrugName":"WARFARIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200315","GenericName":"WARFARIN SODIUM TAB 5 MG","NDC":"76282033210"},{"Id":418534,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"76282033301"},{"Id":418535,"FormularyType":"OHP","DrugName":"WARFARIN TAB 6MG","DosageForm":"TABS - Tablet","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200317","GenericName":"WARFARIN SODIUM TAB 6 MG","NDC":"76282033310"},{"Id":418536,"FormularyType":"OHP","DrugName":"WARFARIN TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200320","GenericName":"WARFARIN SODIUM TAB 7.5 MG","NDC":"76282033401"},{"Id":418537,"FormularyType":"OHP","DrugName":"WARFARIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"COUMARIN ANTICOAGULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83200030200325","GenericName":"WARFARIN SODIUM TAB 10 MG","NDC":"76282033501"},{"Id":418538,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"76282033660"},{"Id":418539,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"76282034001"},{"Id":418540,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"76282034005"},{"Id":418541,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"76282034101"},{"Id":418542,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"76282034105"},{"Id":418543,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"76282034201"},{"Id":418544,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"76282034205"},{"Id":418545,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"76282034701"},{"Id":418546,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"76282034801"},{"Id":418547,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"76282034901"},{"Id":418548,"FormularyType":"OHP","DrugName":"CALC ACETATE CAP 667MG","DosageForm":"CAPS - Capsule","Strength":"667","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800020100120","GenericName":"CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","NDC":"76282037702"},{"Id":418549,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"76282040501"},{"Id":418550,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"76282040505"},{"Id":418551,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"76282040590"},{"Id":418552,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"76282040601"},{"Id":418553,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"76282040605"},{"Id":418554,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"76282040690"},{"Id":418555,"FormularyType":"OHP","DrugName":"SEVELAM CARB TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800070050340","GenericName":"SEVELAMER CARBONATE TAB 800 MG","NDC":"76282040727"},{"Id":418556,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"76282041205"},{"Id":418557,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"76282041230"},{"Id":418558,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"76282041290"},{"Id":418559,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"76282041701"},{"Id":418560,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"76282041705"},{"Id":418561,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282041801"},{"Id":418562,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282041810"},{"Id":418563,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282041845"},{"Id":418564,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282041890"},{"Id":418565,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282041901"},{"Id":418566,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282041910"},{"Id":418567,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282041945"},{"Id":418568,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282041950"},{"Id":418569,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282041990"},{"Id":418570,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282042001"},{"Id":418571,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282042010"},{"Id":418572,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282042018"},{"Id":418573,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282042045"},{"Id":418574,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282042050"},{"Id":418575,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282042090"},{"Id":418576,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"76282042101"},{"Id":418577,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"76282042105"},{"Id":418578,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282042201"},{"Id":418579,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282042210"},{"Id":418580,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282042218"},{"Id":418581,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282042245"},{"Id":418582,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282042290"},{"Id":418583,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"76282044601"},{"Id":418584,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"76282044605"},{"Id":418585,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"76282044610"},{"Id":418586,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 10-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550305","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","NDC":"76282044690"},{"Id":418587,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"76282044701"},{"Id":418588,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"76282044705"},{"Id":418589,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"76282044710"},{"Id":418590,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-12.5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550310","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","NDC":"76282044790"},{"Id":418591,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"76282044801"},{"Id":418592,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"76282044805"},{"Id":418593,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"76282044810"},{"Id":418594,"FormularyType":"OHP","DrugName":"LISINOP/HCTZ TAB 20-25MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIHYPERTENSIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36991802550320","GenericName":"LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","NDC":"76282044890"},{"Id":418595,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"76282046206"},{"Id":418596,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"76282046218"},{"Id":418597,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"76282046306"},{"Id":418598,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"76282046318"},{"Id":418599,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"76282047645"},{"Id":418600,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200540","GenericName":"LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","NDC":"76282047690"},{"Id":418601,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"76282047715"},{"Id":418602,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200550","GenericName":"LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","NDC":"76282047790"},{"Id":418603,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"76282047813"},{"Id":418604,"FormularyType":"OHP","DrugName":"LANTHANUM CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"PHOSPHATE BINDER AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52800045200560","GenericName":"LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","NDC":"76282047890"},{"Id":418605,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"76282050710"},{"Id":418606,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"76282050790"},{"Id":418607,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"76282050810"},{"Id":418608,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"76282050890"},{"Id":418609,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"76282050910"},{"Id":418610,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"76282050990"},{"Id":418611,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"76282056890"},{"Id":418612,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"76282056990"},{"Id":418613,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"76282057090"},{"Id":418614,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"76282057190"},{"Id":418615,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"76282057290"},{"Id":418616,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"76282057390"},{"Id":418617,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"76282057490"},{"Id":418618,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"76282057590"},{"Id":418619,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"76282062705"},{"Id":418620,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"76282064037"},{"Id":418621,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.25MG/2","DosageForm":"SUSP - Suspension","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001830","GenericName":"BUDESONIDE INHALATION SUSP 0.25 MG/2ML","NDC":"76282064038"},{"Id":418622,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"76282064137"},{"Id":418623,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 0.5MG/2","DosageForm":"SUSP - Suspension","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001840","GenericName":"BUDESONIDE INHALATION SUSP 0.5 MG/2ML","NDC":"76282064138"},{"Id":418624,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"76282064237"},{"Id":418625,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 1MG/2ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"STEROID INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44400015001850","GenericName":"BUDESONIDE INHALATION SUSP 1 MG/2ML","NDC":"76282064238"},{"Id":418626,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000110","GenericName":"RAMIPRIL CAP 1.25 MG","NDC":"76282067001"},{"Id":418627,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"76282067101"},{"Id":418628,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000120","GenericName":"RAMIPRIL CAP 2.5 MG","NDC":"76282067105"},{"Id":418629,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"76282067201"},{"Id":418630,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000130","GenericName":"RAMIPRIL CAP 5 MG","NDC":"76282067205"},{"Id":418631,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"76282067301"},{"Id":418632,"FormularyType":"OHP","DrugName":"RAMIPRIL CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100050000140","GenericName":"RAMIPRIL CAP 10 MG","NDC":"76282067305"},{"Id":418633,"FormularyType":"OHP","DrugName":"CINACALCET TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100320","GenericName":"CINACALCET HCL TAB 30 MG (BASE EQUIV)","NDC":"76282067430"},{"Id":418634,"FormularyType":"OHP","DrugName":"CINACALCET TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100330","GenericName":"CINACALCET HCL TAB 60 MG (BASE EQUIV)","NDC":"76282067530"},{"Id":418635,"FormularyType":"OHP","DrugName":"CINACALCET TAB 90MG","DosageForm":"TABS - Tablet","Strength":"90","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30905225100340","GenericName":"CINACALCET HCL TAB 90 MG (BASE EQUIV)","NDC":"76282067630"},{"Id":418636,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"76282067730"},{"Id":418637,"FormularyType":"OHP","DrugName":"EFAVIR/EMTRI TAB TENOFOVI","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109903300320","GenericName":"EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG","NDC":"76282067830"},{"Id":418638,"FormularyType":"OHP","DrugName":"ALBUTEROL AER HFA","DosageForm":"AERS - Aerosol solution","Strength":"108","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"SYMPATHOMIMETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44201010103410","GenericName":"ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","NDC":"76282067942"},{"Id":418639,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 35MG","DosageForm":"TABS - Tablet","Strength":"35","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100335","GenericName":"ALENDRONATE SODIUM TAB 35 MG","NDC":"76282068145"},{"Id":418640,"FormularyType":"OHP","DrugName":"ALENDRONATE TAB 70MG","DosageForm":"TABS - Tablet","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"BONE DENSITY REGULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30042010100370","GenericName":"ALENDRONATE SODIUM TAB 70 MG","NDC":"76282068245"},{"Id":418641,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"76282069648"},{"Id":418642,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"76282069748"},{"Id":418643,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"76282069848"},{"Id":418644,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"76282069947"},{"Id":418645,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"76282070047"},{"Id":418646,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"76282070147"},{"Id":418647,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 30MG","DosageForm":"CAPS - Capsule","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200110","GenericName":"OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","NDC":"76282070245"},{"Id":418648,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 45MG","DosageForm":"CAPS - Capsule","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200115","GenericName":"OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","NDC":"76282070345"},{"Id":418649,"FormularyType":"OHP","DrugName":"OSELTAMIVIR CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060200120","GenericName":"OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","NDC":"76282070445"},{"Id":418650,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"76282070605"},{"Id":418651,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"76282070690"},{"Id":418652,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"76282070705"},{"Id":418653,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"76282070790"},{"Id":418654,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"76282071210"},{"Id":418655,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"76282071246"},{"Id":418656,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000320","GenericName":"IBUPROFEN TAB 400 MG","NDC":"76282071250"},{"Id":418657,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"76282071310"},{"Id":418658,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000330","GenericName":"IBUPROFEN TAB 600 MG","NDC":"76282071350"},{"Id":418659,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"76282071410"},{"Id":418660,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"76282071430"},{"Id":418661,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"76282071446"},{"Id":418662,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"76282071450"},{"Id":418663,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000340","GenericName":"IBUPROFEN TAB 800 MG","NDC":"76282071490"},{"Id":418664,"FormularyType":"OHP","DrugName":"PIRFENIDONE CAP 267MG","DosageForm":"CAPS - Capsule","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000120","GenericName":"PIRFENIDONE CAP 267 MG","NDC":"76282071527"},{"Id":418665,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 801MG","DosageForm":"TABS - Tablet","Strength":"801","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000345","GenericName":"PIRFENIDONE TAB 801 MG","NDC":"76282071690"},{"Id":418666,"FormularyType":"OHP","DrugName":"PIRFENIDONE TAB 267MG","DosageForm":"TABS - Tablet","Strength":"267","BrandVsGeneric":"Y","DrugCategory":"RESPIRATORY AGENTS - MISC.","DrugSubClass":"PULMONARY FIBROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"45550060000325","GenericName":"PIRFENIDONE TAB 267 MG","NDC":"76282071727"},{"Id":418667,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"76282072101"},{"Id":418668,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100105","GenericName":"PRAZOSIN HCL CAP 1 MG","NDC":"76282072110"},{"Id":418669,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"76282072201"},{"Id":418670,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100110","GenericName":"PRAZOSIN HCL CAP 2 MG","NDC":"76282072210"},{"Id":418671,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"76282072301"},{"Id":418672,"FormularyType":"OHP","DrugName":"PRAZOSIN HCL CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANTIADRENERGIC ANTIHYPERTENSIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36202030100115","GenericName":"PRAZOSIN HCL CAP 5 MG","NDC":"76282072325"},{"Id":418673,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"76282072801"},{"Id":418674,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"76282072805"},{"Id":418675,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282072901"},{"Id":418676,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282072910"},{"Id":418677,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282072945"},{"Id":418678,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"76282072990"},{"Id":418679,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282073001"},{"Id":418680,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282073010"},{"Id":418681,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282073045"},{"Id":418682,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282073050"},{"Id":418683,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"76282073090"},{"Id":418684,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282073101"},{"Id":418685,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282073110"},{"Id":418686,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282073118"},{"Id":418687,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282073145"},{"Id":418688,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282073150"},{"Id":418689,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"76282073190"},{"Id":418690,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"76282073201"},{"Id":418691,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000324","GenericName":"LISINOPRIL TAB 30 MG","NDC":"76282073205"},{"Id":418692,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282073301"},{"Id":418693,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282073310"},{"Id":418694,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282073318"},{"Id":418695,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282073345"},{"Id":418696,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"76282073390"},{"Id":418697,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000325","GenericName":"DARUNAVIR TAB 600 MG","NDC":"76282073760"},{"Id":418698,"FormularyType":"OHP","DrugName":"DARUNAVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12104520000350","GenericName":"DARUNAVIR TAB 800 MG","NDC":"76282073830"},{"Id":418699,"FormularyType":"OHP","DrugName":"OSELTAMIVIR SUS 6MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"6","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"INFLUENZA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12504060201910","GenericName":"OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","NDC":"76282073952"},{"Id":418700,"FormularyType":"OHP","DrugName":"PHYTONADIONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77204030000305","GenericName":"PHYTONADIONE TAB 5 MG","NDC":"76282074030"},{"Id":418701,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"76282074405"},{"Id":418702,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"76282074490"},{"Id":418703,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000110","GenericName":"DOFETILIDE CAP 125 MCG (0.125 MG)","NDC":"76282075560"},{"Id":418704,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000120","GenericName":"DOFETILIDE CAP 250 MCG (0.25 MG)","NDC":"76282075660"},{"Id":418705,"FormularyType":"OHP","DrugName":"DOFETILIDE CAP 500MCG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE III","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35400025000130","GenericName":"DOFETILIDE CAP 500 MCG (0.5 MG)","NDC":"76282075760"},{"Id":418706,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 3","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"76282078140"},{"Id":418707,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 2","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"76282078240"},{"Id":418708,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS STEP 1","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"76282078340"},{"Id":418709,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"76282079401"},{"Id":418710,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100305","GenericName":"METOPROLOL TARTRATE TAB 25 MG","NDC":"76282079410"},{"Id":418711,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"76282079501"},{"Id":418712,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100310","GenericName":"METOPROLOL TARTRATE TAB 50 MG","NDC":"76282079510"},{"Id":418713,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"76282079601"},{"Id":418714,"FormularyType":"OHP","DrugName":"METOPROL TAR TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030100315","GenericName":"METOPROLOL TARTRATE TAB 100 MG","NDC":"76282079610"},{"Id":418715,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"76282079701"},{"Id":418716,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"76282079801"},{"Id":418717,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"76282079805"},{"Id":418718,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"76282079901"},{"Id":418719,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"76282079905"},{"Id":418720,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000101"},{"Id":418721,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000102"},{"Id":418722,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000111"},{"Id":418723,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000112"},{"Id":418724,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000121"},{"Id":418725,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000122"},{"Id":418726,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000131"},{"Id":418727,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000132"},{"Id":418728,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000141"},{"Id":418729,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"76297000142"},{"Id":418730,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 1MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"76329146901"},{"Id":418731,"FormularyType":"OHP","DrugName":"MORPHIN/NACL INJ 30/30ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - OPIOID","DrugSubClass":"OPIOID AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"65100055102056","GenericName":"MORPHINE SULFATE IV SOLN PF 1 MG/ML","NDC":"76329191201"},{"Id":418732,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2% JELLY","DosageForm":"PRSY - Prefilled Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9085006010E420","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","NDC":"76329301105"},{"Id":418733,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2% JELLY","DosageForm":"PRSY - Prefilled Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9085006010E420","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","NDC":"76329301205"},{"Id":418734,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2% JELLY","DosageForm":"PRSY - Prefilled Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9085006010E420","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","NDC":"76329301305"},{"Id":418735,"FormularyType":"OHP","DrugName":"LIDOCAINE GEL 2%","DosageForm":"PRSY - Prefilled Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9085006010E420","GenericName":"LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","NDC":"76329301505"},{"Id":418736,"FormularyType":"OHP","DrugName":"DEXTROSE INJ 50%","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"CARBOHYDRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80100020002050","GenericName":"DEXTROSE INJ 50%","NDC":"76329330201"},{"Id":418737,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"76329335201"},{"Id":418738,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 1MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"76329336901"},{"Id":418739,"FormularyType":"OHP","DrugName":"LIDOCAINE INJ 100/5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"N","DrugCategory":"LOCAL ANESTHETICS-PARENTERAL","DrugSubClass":"LOCAL ANESTHETICS - AMIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6910004010E530","GenericName":"LIDOCAINE HCL LOCAL SOLN PREFILLED SYRINGE 100 MG/5ML (2%)","NDC":"76329339001"},{"Id":418740,"FormularyType":"OHP","DrugName":"PROCAINAMIDE INJ 100MG/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-A","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35100020102010","GenericName":"PROCAINAMIDE HCL INJ 100 MG/ML","NDC":"76329339905"},{"Id":418741,"FormularyType":"OHP","DrugName":"NALOXONE HCL INJ 1MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9340002010E540","GenericName":"NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","NDC":"76329346901"},{"Id":418742,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"N","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANESTHETICS TOPICAL ORAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88350065102045","GenericName":"LIDOCAINE HCL LARYNGOTRACHEAL SOLN 4%","NDC":"76329630005"},{"Id":418743,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"76329826100"},{"Id":418744,"FormularyType":"OHP","DrugName":"LORAZEPAM INJ 2MG/ML","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"BENZODIAZEPINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57100060002005","GenericName":"LORAZEPAM INJ 2 MG/ML","NDC":"76329826101"},{"Id":418745,"FormularyType":"OHP","DrugName":"LYSODREN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21402250000320","GenericName":"MITOTANE TAB 500 MG","NDC":"76336008060"},{"Id":418746,"FormularyType":"OHP","DrugName":"KETOTIF FUM DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"76385010617"},{"Id":418747,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"76385010701"},{"Id":418748,"FormularyType":"OHP","DrugName":"DIPHEN/ATROP TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIPERISTALTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47100010100310","GenericName":"DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","NDC":"76385010710"},{"Id":418749,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"76385011001"},{"Id":418750,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"76385011050"},{"Id":418751,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"76385011101"},{"Id":418752,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"76385011150"},{"Id":418753,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"76385011250"},{"Id":418754,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"76385011301"},{"Id":418755,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"76385011350"},{"Id":418756,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100310","GenericName":"SOTALOL HCL TAB 80 MG","NDC":"76385011401"},{"Id":418757,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100315","GenericName":"SOTALOL HCL TAB 120 MG","NDC":"76385011501"},{"Id":418758,"FormularyType":"OHP","DrugName":"SOTALOL HCL TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045100320","GenericName":"SOTALOL HCL TAB 160 MG","NDC":"76385011601"},{"Id":418759,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000310","GenericName":"ETODOLAC TAB 400 MG","NDC":"76385011801"},{"Id":418760,"FormularyType":"OHP","DrugName":"ETODOLAC TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000320","GenericName":"ETODOLAC TAB 500 MG","NDC":"76385011901"},{"Id":418761,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"76385012301"},{"Id":418762,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000305","GenericName":"METHOCARBAMOL TAB 500 MG","NDC":"76385012350"},{"Id":418763,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"76385012401"},{"Id":418764,"FormularyType":"OHP","DrugName":"METHOCARBAM TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100070000310","GenericName":"METHOCARBAMOL TAB 750 MG","NDC":"76385012450"},{"Id":418765,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120310","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 80 MG","NDC":"76385012501"},{"Id":418766,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 120MG","DosageForm":"TABS - Tablet","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120315","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 120 MG","NDC":"76385012601"},{"Id":418767,"FormularyType":"OHP","DrugName":"SOTALOL AF TAB 160MG","DosageForm":"TABS - Tablet","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100045120320","GenericName":"SOTALOL HCL (AFIB/AFL) TAB 160 MG","NDC":"76385012701"},{"Id":418768,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"76385012810"},{"Id":418769,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"76385012901"},{"Id":418770,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"76385012950"},{"Id":418771,"FormularyType":"OHP","DrugName":"CYPROHEPTAD TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - PIPERIDINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41500020100305","GenericName":"CYPROHEPTADINE HCL TAB 4 MG","NDC":"76385013001"},{"Id":418772,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000305","GenericName":"PINDOLOL TAB 5 MG","NDC":"76385013101"},{"Id":418773,"FormularyType":"OHP","DrugName":"PINDOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100030000310","GenericName":"PINDOLOL TAB 10 MG","NDC":"76385013201"},{"Id":418774,"FormularyType":"OHP","DrugName":"NADOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000303","GenericName":"NADOLOL TAB 20 MG","NDC":"76385013301"},{"Id":418775,"FormularyType":"OHP","DrugName":"NADOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000305","GenericName":"NADOLOL TAB 40 MG","NDC":"76385013401"},{"Id":418776,"FormularyType":"OHP","DrugName":"NADOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100010000310","GenericName":"NADOLOL TAB 80 MG","NDC":"76385013501"},{"Id":418777,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"76385013601"},{"Id":418778,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"76385013701"},{"Id":418779,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"76385013801"},{"Id":418780,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100303","GenericName":"FLECAINIDE ACETATE TAB 50 MG","NDC":"76385014501"},{"Id":418781,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100305","GenericName":"FLECAINIDE ACETATE TAB 100 MG","NDC":"76385014601"},{"Id":418782,"FormularyType":"OHP","DrugName":"FLECAINIDE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIARRHYTHMICS","DrugSubClass":"ANTIARRHYTHMICS TYPE I-C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"35300010100310","GenericName":"FLECAINIDE ACETATE TAB 150 MG","NDC":"76385014701"},{"Id":418783,"FormularyType":"OHP","DrugName":"STERIL WATER INJ","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"PHARMACEUTICAL ADJUVANTS","DrugSubClass":"LIQUID VEHICLES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"98401010002000","GenericName":"WATER FOR INJECTION","NDC":"76420008210"},{"Id":418784,"FormularyType":"OHP","DrugName":"IS-D 10000 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"76420011430"},{"Id":418785,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 10000UNT","DosageForm":"TABS - Tablet","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"76420011630"},{"Id":418786,"FormularyType":"OHP","DrugName":"TRIAMCINOLON CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550085103710","GenericName":"TRIAMCINOLONE ACETONIDE CREAM 0.1%","NDC":"76420020315"},{"Id":418787,"FormularyType":"OHP","DrugName":"BPROTECT PED DRO TRI-VITE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002017","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 412.5 MCG-10 MCG-35MG/ML***","NDC":"76518002050"},{"Id":418788,"FormularyType":"OHP","DrugName":"POLY-VITE DRO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"76518003050"},{"Id":418789,"FormularyType":"OHP","DrugName":"POLY-VITE SOL /IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"76518004050"},{"Id":418790,"FormularyType":"OHP","DrugName":"PEDIA D-VITE DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"76518005050"},{"Id":418791,"FormularyType":"OHP","DrugName":"PEDIA IRON DRO 15MG/ML","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"76518006050"},{"Id":418792,"FormularyType":"OHP","DrugName":"SENNAZON SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"76518010008"},{"Id":418793,"FormularyType":"OHP","DrugName":"MELATONIN SUB 5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000740","GenericName":"MELATONIN SL TAB 5 MG","NDC":"76635090740"},{"Id":418794,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"77333003120"},{"Id":418795,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"77333003125"},{"Id":418796,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"77333004920"},{"Id":418797,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"77333004925"},{"Id":418798,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"77333011010"},{"Id":418799,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"77333011025"},{"Id":418800,"FormularyType":"OHP","DrugName":"CAL CIT+D3 TAB MAXIMUM","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"77333011310"},{"Id":418801,"FormularyType":"OHP","DrugName":"CAL CIT+D3 TAB MAXIMUM","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"77333011325"},{"Id":418802,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"77333011510"},{"Id":418803,"FormularyType":"OHP","DrugName":"CALCIUM/D TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"77333011525"},{"Id":418804,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"77333011810"},{"Id":418805,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"77333011825"},{"Id":418806,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"77333012025"},{"Id":418807,"FormularyType":"OHP","DrugName":"FIBER LAXATV TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"77333012050"},{"Id":418808,"FormularyType":"OHP","DrugName":"CHILD CHEW CHW VITAMINS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"77333014610"},{"Id":418809,"FormularyType":"OHP","DrugName":"CHILD CHEW CHW VITAMINS","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"77333014625"},{"Id":418810,"FormularyType":"OHP","DrugName":"FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"77333030710"},{"Id":418811,"FormularyType":"OHP","DrugName":"FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"77333030725"},{"Id":418812,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"77333030810"},{"Id":418813,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"77333030825"},{"Id":418814,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"77333050120"},{"Id":418815,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"77333050125"},{"Id":418816,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"77333051610"},{"Id":418817,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"77333051625"},{"Id":418818,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"77333052010"},{"Id":418819,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"77333052025"},{"Id":418820,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"77333071510"},{"Id":418821,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000322","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***","NDC":"77333071525"},{"Id":418822,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 10GR","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"77333082710"},{"Id":418823,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 10GR","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"77333082725"},{"Id":418824,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"77333083110"},{"Id":418825,"FormularyType":"OHP","DrugName":"SODIUM BICAR TAB 650MG","DosageForm":"TABS - Tablet","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - BICARBONATE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48200010000325","GenericName":"SODIUM BICARBONATE TAB 650 MG","NDC":"77333083125"},{"Id":418826,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"77333093410"},{"Id":418827,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"77333093425"},{"Id":418828,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"77333093710"},{"Id":418829,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"77333093725"},{"Id":418830,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"77333093810"},{"Id":418831,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"77333093825"},{"Id":418832,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"77333094010"},{"Id":418833,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"77333094025"},{"Id":418834,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"77333094510"},{"Id":418835,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"77333094525"},{"Id":418836,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"77333094810"},{"Id":418837,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"77333094825"},{"Id":418838,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"77771012410"},{"Id":418839,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"77771012430"},{"Id":418840,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"77771012490"},{"Id":418841,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"77771015701"},{"Id":418842,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"77771015705"},{"Id":418843,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"77771015801"},{"Id":418844,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"77771015805"},{"Id":418845,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"77771017705"},{"Id":418846,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"77771017790"},{"Id":418847,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"77771017805"},{"Id":418848,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"77771017890"},{"Id":418849,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"77771018201"},{"Id":418850,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100305","GenericName":"HYDRALAZINE HCL TAB 10 MG","NDC":"77771018210"},{"Id":418851,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"77771018301"},{"Id":418852,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100310","GenericName":"HYDRALAZINE HCL TAB 25 MG","NDC":"77771018310"},{"Id":418853,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"77771018401"},{"Id":418854,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100315","GenericName":"HYDRALAZINE HCL TAB 50 MG","NDC":"77771018410"},{"Id":418855,"FormularyType":"OHP","DrugName":"HYDRALAZINE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"VASODILATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36400010100320","GenericName":"HYDRALAZINE HCL TAB 100 MG","NDC":"77771018501"},{"Id":418856,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"77771020101"},{"Id":418857,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"77771020105"},{"Id":418858,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"77771020201"},{"Id":418859,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"77771020205"},{"Id":418860,"FormularyType":"OHP","DrugName":"FEXOFENADINE TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"77771020230"},{"Id":418861,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000310","GenericName":"FLUCONAZOLE TAB 50 MG","NDC":"77771039630"},{"Id":418862,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"77771039701"},{"Id":418863,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000320","GenericName":"FLUCONAZOLE TAB 100 MG","NDC":"77771039730"},{"Id":418864,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"77771039811"},{"Id":418865,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000325","GenericName":"FLUCONAZOLE TAB 150 MG","NDC":"77771039813"},{"Id":418866,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"77771039901"},{"Id":418867,"FormularyType":"OHP","DrugName":"FLUCONAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIFUNGALS","DrugSubClass":"IMIDAZOLE-RELATED ANTIFUNGALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"11407015000330","GenericName":"FLUCONAZOLE TAB 200 MG","NDC":"77771039930"},{"Id":418868,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 500MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007420","GenericName":"RANOLAZINE TAB ER 12HR 500 MG","NDC":"77771042360"},{"Id":418869,"FormularyType":"OHP","DrugName":"RANOLAZINE TAB 1000MG","DosageForm":"TB12 - Tablet ER 12HR","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"ANTIANGINALS-OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32200040007430","GenericName":"RANOLAZINE TAB ER 12HR 1000 MG","NDC":"77771042460"},{"Id":418870,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"77771043401"},{"Id":418871,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000305","GenericName":"NAPROXEN TAB 250 MG","NDC":"77771043405"},{"Id":418872,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"77771043501"},{"Id":418873,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 375MG","DosageForm":"TABS - Tablet","Strength":"375","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000310","GenericName":"NAPROXEN TAB 375 MG","NDC":"77771043505"},{"Id":418874,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"77771043601"},{"Id":418875,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"77771043605"},{"Id":418876,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"77771045110"},{"Id":418877,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"77771045190"},{"Id":418878,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"77771045205"},{"Id":418879,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"77771045290"},{"Id":418880,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"77771045310"},{"Id":418881,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"77771045390"},{"Id":418882,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"77771045405"},{"Id":418883,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"77771045490"},{"Id":418884,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 25-100MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100410","GenericName":"CARBIDOPA & LEVODOPA TAB ER 25-100 MG","NDC":"77771046001"},{"Id":418885,"FormularyType":"OHP","DrugName":"CARB/LEVO ER TAB 50-200MG","DosageForm":"TBCR - Tablet ER","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIPARKINSON AND RELATED THERAPY AGENTS","DrugSubClass":"ANTIPARKINSON DOPAMINERGICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"73209902100420","GenericName":"CARBIDOPA & LEVODOPA TAB ER 50-200 MG","NDC":"77771046101"},{"Id":418886,"FormularyType":"OHP","DrugName":"HADLIMA INJ 40/0.8ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001520E520","GenericName":"ADALIMUMAB-BWWD SOLN PREFILLED SYRINGE 40 MG/0.8ML","NDC":"78206018301"},{"Id":418887,"FormularyType":"OHP","DrugName":"HADLIMA PUSH INJ 40/0.8ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001520D520","GenericName":"ADALIMUMAB-BWWD SOLN AUTO-INJECTOR 40 MG/0.8ML","NDC":"78206018401"},{"Id":418888,"FormularyType":"OHP","DrugName":"HADLIMA INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001520E510","GenericName":"ADALIMUMAB-BWWD SOLN PREFILLED SYRINGE 40 MG/0.4ML","NDC":"78206018601"},{"Id":418889,"FormularyType":"OHP","DrugName":"HADLIMA PUSH INJ 40/0.4ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001520D510","GenericName":"ADALIMUMAB-BWWD SOLN AUTO-INJECTOR 40 MG/0.4ML","NDC":"78206018701"},{"Id":418890,"FormularyType":"OHP","DrugName":"ALBENDAZOLE TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTHELMINTICS","DrugSubClass":"ANTHELMINTICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"15000002000320","GenericName":"ALBENDAZOLE TAB 200 MG","NDC":"78482011002"},{"Id":418891,"FormularyType":"OHP","DrugName":"IWILFIN TAB 192MG","DosageForm":"TABS - Tablet","Strength":"192","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21757220300320","GenericName":"EFLORNITHINE HCL TAB 192 MG","NDC":"78670015001"},{"Id":418892,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"78742000325"},{"Id":418893,"FormularyType":"OHP","DrugName":"SV VIT B-12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"78742000985"},{"Id":418894,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"78742000986"},{"Id":418895,"FormularyType":"OHP","DrugName":"B-12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"78742000987"},{"Id":418896,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"78742002344"},{"Id":418897,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"78742002345"},{"Id":418898,"FormularyType":"OHP","DrugName":"EQ ALLERGY SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"78742002621"},{"Id":418899,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"78742006334"},{"Id":418900,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"78742007189"},{"Id":418901,"FormularyType":"OHP","DrugName":"MM CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"78742008961"},{"Id":418902,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"78742009060"},{"Id":418903,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"78742009146"},{"Id":418904,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"78742009257"},{"Id":418905,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"78742009265"},{"Id":418906,"FormularyType":"OHP","DrugName":"FIBER THERAP CAP 0.52GM","DosageForm":"CAPS - Capsule","Strength":"0.52","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030100132","GenericName":"PSYLLIUM CAP 0.52 GM","NDC":"78742009269"},{"Id":418907,"FormularyType":"OHP","DrugName":"MM MELATONIN TAB 10MG TR","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000440","GenericName":"MELATONIN TAB ER 10 MG","NDC":"78742009463"},{"Id":418908,"FormularyType":"OHP","DrugName":"JOCK ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"78742012307"},{"Id":418909,"FormularyType":"OHP","DrugName":"ANTACID EXTR CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"78742014586"},{"Id":418910,"FormularyType":"OHP","DrugName":"MM FEXOFENAD TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"78742023550"},{"Id":418911,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"78742025657"},{"Id":418912,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1/2ML/30","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"78742025659"},{"Id":418913,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"78742025661"},{"Id":418914,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3ML/31","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"78742025663"},{"Id":418915,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1/2ML/31","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"78742025665"},{"Id":418916,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"78742025767"},{"Id":418917,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"78742025772"},{"Id":418918,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"78742025773"},{"Id":418919,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"78742025774"},{"Id":418920,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"78742025775"},{"Id":418921,"FormularyType":"OHP","DrugName":"MM ASPIRIN TAB LOW DOSE","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"78742028816"},{"Id":418922,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"78742043518"},{"Id":418923,"FormularyType":"OHP","DrugName":"B6 NATURAL TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"78742043574"},{"Id":418924,"FormularyType":"OHP","DrugName":"B1 NATURAL TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200330","GenericName":"THIAMINE MONONITRATE TAB 250 MG","NDC":"78742043588"},{"Id":418925,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"78742043656"},{"Id":418926,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"78742045610"},{"Id":418927,"FormularyType":"OHP","DrugName":"WEIGHT LOSS LIQ SHK CHOC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"78742045614"},{"Id":418928,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"78742049911"},{"Id":418929,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.035%","DosageForm":"CREA - Cream","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003715","GenericName":"CAPSAICIN CREAM 0.035%","NDC":"79643001101"},{"Id":418930,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061301"},{"Id":418931,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061302"},{"Id":418932,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061303"},{"Id":418933,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061304"},{"Id":418934,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061305"},{"Id":418935,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061310"},{"Id":418936,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061320"},{"Id":418937,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061330"},{"Id":418938,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061340"},{"Id":418939,"FormularyType":"OHP","DrugName":"SOD CHLORIDE INJ 0.9%","DosageForm":"SOLN - Solution","Strength":"0.9","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"SODIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79750010002021","GenericName":"SODIUM CHLORIDE IV SOLN 0.9%","NDC":"79672061350"},{"Id":418940,"FormularyType":"OHP","DrugName":"REZUROCK TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99398510500320","GenericName":"BELUMOSUDIL MESYLATE TAB 200 MG","NDC":"79802020030"},{"Id":418941,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"79854000260"},{"Id":418942,"FormularyType":"OHP","DrugName":"MELATONIN SUB 5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000740","GenericName":"MELATONIN SL TAB 5 MG","NDC":"79854000615"},{"Id":418943,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"79854000715"},{"Id":418944,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB /VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"79854000732"},{"Id":418945,"FormularyType":"OHP","DrugName":"LIQ CA/VIT D CAP 600MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630150","GenericName":"CALCIUM CARBONATE-VITAMIN D CAP 600 MG-5 MCG (200 UNIT)","NDC":"79854000735"},{"Id":418946,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"79854000893"},{"Id":418947,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"79854001001"},{"Id":418948,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"79854001109"},{"Id":418949,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"79854001162"},{"Id":418950,"FormularyType":"OHP","DrugName":"FULL SPECT TAB B/ VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ FOLIC ACID","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78133000000325","GenericName":"*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG***","NDC":"79854001269"},{"Id":418951,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"79854001609"},{"Id":418952,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"79854001680"},{"Id":418953,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB /VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"79854001681"},{"Id":418954,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"79854003163"},{"Id":418955,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"79854004112"},{"Id":418956,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"79854005023"},{"Id":418957,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"79854005024"},{"Id":418958,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG CR","DosageForm":"TBCR - Tablet ER","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000420","GenericName":"MELATONIN TAB ER 3 MG","NDC":"79854005026"},{"Id":418959,"FormularyType":"OHP","DrugName":"OMEGA-3 FISH CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"79854006900"},{"Id":418960,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"79854007009"},{"Id":418961,"FormularyType":"OHP","DrugName":"VITAMIN D3 DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"79854007723"},{"Id":418962,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"79854007742"},{"Id":418963,"FormularyType":"OHP","DrugName":"CALCIUM CIT/ TAB VIT D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"79854007747"},{"Id":418964,"FormularyType":"OHP","DrugName":"SLOW IRON TAB 160MG ER","DosageForm":"TBCR - Tablet ER","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100410","GenericName":"FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT)","NDC":"79854007749"},{"Id":418965,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"79854007941"},{"Id":418966,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"79854007986"},{"Id":418967,"FormularyType":"OHP","DrugName":"MELATONIN TR TAB 1MG","DosageForm":"TBCR - Tablet ER","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000405","GenericName":"MELATONIN TAB ER 1 MG","NDC":"79854008983"},{"Id":418968,"FormularyType":"OHP","DrugName":"PRENATAL CAP FORMULA","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512018000115","GenericName":"*PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-0.8-235 MG***","NDC":"79854008992"},{"Id":418969,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"79854009097"},{"Id":418970,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"79854009098"},{"Id":418971,"FormularyType":"OHP","DrugName":"VITACHEW D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"79854009164"},{"Id":418972,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"79854009291"},{"Id":418973,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"79854009305"},{"Id":418974,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"79854009310"},{"Id":418975,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"79854009330"},{"Id":418976,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"79854009332"},{"Id":418977,"FormularyType":"OHP","DrugName":"NIACIN TAB 250MG TR","DosageForm":"TBCR - Tablet ER","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000440","GenericName":"NIACIN TAB ER 250 MG","NDC":"79854010076"},{"Id":418978,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG TR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"79854010078"},{"Id":418979,"FormularyType":"OHP","DrugName":"CALCIUM CARB TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"79854010830"},{"Id":418980,"FormularyType":"OHP","DrugName":"CALCIUM CARB CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000515","GenericName":"CALCIUM CARBONATE CHEW TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"79854010892"},{"Id":418981,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"79854011893"},{"Id":418982,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"79854020010"},{"Id":418983,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"79854020030"},{"Id":418984,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"79854020035"},{"Id":418985,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"79854020050"},{"Id":418986,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"79854020055"},{"Id":418987,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"79854020060"},{"Id":418988,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"79854020062"},{"Id":418989,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"79854020115"},{"Id":418990,"FormularyType":"OHP","DrugName":"NIACIN TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000320","GenericName":"NIACIN TAB 50 MG","NDC":"79854020125"},{"Id":418991,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"79854020983"},{"Id":418992,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"79854023161"},{"Id":418993,"FormularyType":"OHP","DrugName":"CHILDREN VIT CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"79854040015"},{"Id":418994,"FormularyType":"OHP","DrugName":"CHILDREN VIT CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"79854040020"},{"Id":418995,"FormularyType":"OHP","DrugName":"PRENATAL/FE TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512000000315","GenericName":"*PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG***","NDC":"79854040070"},{"Id":418996,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"79854050015"},{"Id":418997,"FormularyType":"OHP","DrugName":"OYST SHELL/D TAB 250MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902630330","GenericName":"CALCIUM CARBONATE-VITAMIN D TAB 250 MG-3.125 MCG (125 UNIT)","NDC":"79854050020"},{"Id":418998,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"79854050021"},{"Id":418999,"FormularyType":"OHP","DrugName":"PURE CALCIUM TAB CARBONAT","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"79854050022"},{"Id":419000,"FormularyType":"OHP","DrugName":"FERROUS GLUC TAB 324MG","DosageForm":"TABS - Tablet","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000318","GenericName":"FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON)","NDC":"79854050032"},{"Id":419001,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 2MEQ","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000310","GenericName":"POTASSIUM GLUCONATE TAB 2 MEQ","NDC":"79854050060"},{"Id":419002,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"79854051280"},{"Id":419003,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"79854051281"},{"Id":419004,"FormularyType":"OHP","DrugName":"DSS CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"79854061068"},{"Id":419005,"FormularyType":"OHP","DrugName":"DOCUSATE SOD CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"79854070061"},{"Id":419006,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"79854073303"},{"Id":419007,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"79854090040"},{"Id":419008,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 450MG","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"79854090045"},{"Id":419009,"FormularyType":"OHP","DrugName":"EQ OLOPATADI SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"79903000040"},{"Id":419010,"FormularyType":"OHP","DrugName":"EQ OLOPATADI SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"79903000141"},{"Id":419011,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"79903000912"},{"Id":419012,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"79903000924"},{"Id":419013,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"79903003202"},{"Id":419014,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"79903003210"},{"Id":419015,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"79903003240"},{"Id":419016,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"79903005610"},{"Id":419017,"FormularyType":"OHP","DrugName":"EQVEGETABLE TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"79903006410"},{"Id":419018,"FormularyType":"OHP","DrugName":"EQ STOOL SOF CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"79903007314"},{"Id":419019,"FormularyType":"OHP","DrugName":"EQ ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"79903007412"},{"Id":419020,"FormularyType":"OHP","DrugName":"EQ ALRGY REL TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"79903009015"},{"Id":419021,"FormularyType":"OHP","DrugName":"EQ HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"79903009101"},{"Id":419022,"FormularyType":"OHP","DrugName":"EQ LAXATIVE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"79903009608"},{"Id":419023,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"79903011430"},{"Id":419024,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"79903012808"},{"Id":419025,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"79903013099"},{"Id":419026,"FormularyType":"OHP","DrugName":"EQ ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"79903013225"},{"Id":419027,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"79903013724"},{"Id":419028,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"79903013799"},{"Id":419029,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"79903015610"},{"Id":419030,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"79903015612"},{"Id":419031,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"79903015645"},{"Id":419032,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"79903015699"},{"Id":419033,"FormularyType":"OHP","DrugName":"EQ PAIN RELI SUS 160MG/5","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"79903017204"},{"Id":419034,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"79903017508"},{"Id":419035,"FormularyType":"OHP","DrugName":"EQ PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"79903026922"},{"Id":419036,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"79903029910"},{"Id":419037,"FormularyType":"OHP","DrugName":"EQ VEGE LAXA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"79903032210"},{"Id":419038,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"79903048150"},{"Id":419039,"FormularyType":"OHP","DrugName":"LOMUSTINE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21102020000110","GenericName":"LOMUSTINE CAP 10 MG","NDC":"80005011402"},{"Id":419040,"FormularyType":"OHP","DrugName":"LOMUSTINE CAP 40MG","DosageForm":"CAPS - Capsule","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21102020000115","GenericName":"LOMUSTINE CAP 40 MG","NDC":"80005011502"},{"Id":419041,"FormularyType":"OHP","DrugName":"LOMUSTINE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21102020000120","GenericName":"LOMUSTINE CAP 100 MG","NDC":"80005011602"},{"Id":419042,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"80005011711"},{"Id":419043,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000305","GenericName":"PRIMIDONE TAB 50 MG","NDC":"80005011714"},{"Id":419044,"FormularyType":"OHP","DrugName":"PRIMIDONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600060000310","GenericName":"PRIMIDONE TAB 250 MG","NDC":"80005011811"},{"Id":419045,"FormularyType":"OHP","DrugName":"FAMOTIDINE SUS 40MG/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"49200030001920","GenericName":"FAMOTIDINE FOR SUSP 40 MG/5ML","NDC":"80005011916"},{"Id":419046,"FormularyType":"OHP","DrugName":"BALSALAZIDE CAP 750MG","DosageForm":"CAPS - Capsule","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INFLAMMATORY BOWEL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52500020100120","GenericName":"BALSALAZIDE DISODIUM CAP 750 MG","NDC":"80005012625"},{"Id":419047,"FormularyType":"OHP","DrugName":"ZORYVE CRE 0.05%","DosageForm":"CREA - Cream","Strength":"0.05","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230061003710","GenericName":"ROFLUMILAST CREAM 0.05%","NDC":"80610010560"},{"Id":419048,"FormularyType":"OHP","DrugName":"ZORYVE CRE 0.15%","DosageForm":"CREA - Cream","Strength":"0.15","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230061003720","GenericName":"ROFLUMILAST CREAM 0.15%","NDC":"80610011560"},{"Id":419049,"FormularyType":"OHP","DrugName":"ZORYVE CRE 0.3%","DosageForm":"CREA - Cream","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230061003730","GenericName":"ROFLUMILAST CREAM 0.3%","NDC":"80610013060"},{"Id":419050,"FormularyType":"OHP","DrugName":"ZORYVE MIS 0.3%","DosageForm":"FOAM - Foam","Strength":"0.3","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90230061003920","GenericName":"ROFLUMILAST FOAM 0.3%","NDC":"80610043060"},{"Id":419051,"FormularyType":"OHP","DrugName":"NUVAXOVID INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000260E630","GenericName":"COVID-19 SUBUNIT VACC-NOVAVAX IM SUSP PREF SYR 5 MCG/0.5ML","NDC":"80631020701"},{"Id":419052,"FormularyType":"OHP","DrugName":"NUVAXOVID INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"5","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000260E630","GenericName":"COVID-19 SUBUNIT VACC-NOVAVAX IM SUSP PREF SYR 5 MCG/0.5ML","NDC":"80631020710"},{"Id":419053,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"80681000400"},{"Id":419054,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"80681000500"},{"Id":419055,"FormularyType":"OHP","DrugName":"NIACINAMIDE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103020000315","GenericName":"NIACINAMIDE TAB 500 MG","NDC":"80681001900"},{"Id":419056,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"80681002500"},{"Id":419057,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-400","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"80681002900"},{"Id":419058,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"80681004000"},{"Id":419059,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"80681004001"},{"Id":419060,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"80681004002"},{"Id":419061,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"80681004100"},{"Id":419062,"FormularyType":"OHP","DrugName":"CA CIT/VIT D TAB 315-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"80681004500"},{"Id":419063,"FormularyType":"OHP","DrugName":"MULTIVITAMIN CHW CHILDREN","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"80681004900"},{"Id":419064,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1200MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000195","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1200 MG**","NDC":"80681005500"},{"Id":419065,"FormularyType":"OHP","DrugName":"NIACIN TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000330","GenericName":"NIACIN TAB 100 MG","NDC":"80681005700"},{"Id":419066,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100070000320","GenericName":"OYSTER SHELL CALCIUM TAB 500 MG","NDC":"80681005800"},{"Id":419067,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 100MCG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000315","GenericName":"CYANOCOBALAMIN TAB 100 MCG","NDC":"80681007100"},{"Id":419068,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"80681007200"},{"Id":419069,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"80681007400"},{"Id":419070,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"80681008500"},{"Id":419071,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"80681008600"},{"Id":419072,"FormularyType":"OHP","DrugName":"CALCIUM CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640520","GenericName":"CALCIUM CARB-CHOLECALCIF CHEW TAB 500 MG-2.5MCG (100 UNIT)","NDC":"80681008900"},{"Id":419073,"FormularyType":"OHP","DrugName":"NIACIN TAB 500MG TR","DosageForm":"TBCR - Tablet ER","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000450","GenericName":"NIACIN TAB ER 500 MG","NDC":"80681009000"},{"Id":419074,"FormularyType":"OHP","DrugName":"REGULOID POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"80681009500"},{"Id":419075,"FormularyType":"OHP","DrugName":"REGULOID POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"80681009501"},{"Id":419076,"FormularyType":"OHP","DrugName":"REGULOID POW ORANGE","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"80681009600"},{"Id":419077,"FormularyType":"OHP","DrugName":"REGULOID POW ORANGE","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"80681009601"},{"Id":419078,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100320","GenericName":"THIAMINE HCL TAB 50 MG","NDC":"80681009700"},{"Id":419079,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"80681009800"},{"Id":419080,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"80681009900"},{"Id":419081,"FormularyType":"OHP","DrugName":"GLUCOSE CHW 4GM","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"80681010000"},{"Id":419082,"FormularyType":"OHP","DrugName":"CA CIT/VIT D TAB 315-200","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"80681011500"},{"Id":419083,"FormularyType":"OHP","DrugName":"CHILDRENS CHW MULTIVIT","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"80681011600"},{"Id":419084,"FormularyType":"OHP","DrugName":"VIT B COMPLX TAB /VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"80681012600"},{"Id":419085,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"80681012800"},{"Id":419086,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"80681013100"},{"Id":419087,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"80681013200"},{"Id":419088,"FormularyType":"OHP","DrugName":"CALCIUM CHW 500-10","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640525","GenericName":"CALCIUM CARB-CHOLECALCIF CHEW TAB 500 MG-10 MCG (400 UNIT)","NDC":"80681013700"},{"Id":419089,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"80681013800"},{"Id":419090,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"80681013801"},{"Id":419091,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"80681013900"},{"Id":419092,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"80681013901"},{"Id":419093,"FormularyType":"OHP","DrugName":"CALCIUM CITR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100015000310","GenericName":"CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA)","NDC":"80681014000"},{"Id":419094,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"80681014800"},{"Id":419095,"FormularyType":"OHP","DrugName":"VIT B COMPLX TAB /VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"80681015700"},{"Id":419096,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"80681016800"},{"Id":419097,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"80681016801"},{"Id":419098,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"80681016900"},{"Id":419099,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"80681017000"},{"Id":419100,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50000UNT","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"80681017400"},{"Id":419101,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1.25MG","DosageForm":"CAPS - Capsule","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000180","GenericName":"CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","NDC":"80681017401"},{"Id":419102,"FormularyType":"OHP","DrugName":"LEUKERAN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21101010000305","GenericName":"CHLORAMBUCIL TAB 2 MG","NDC":"80725061025"},{"Id":419103,"FormularyType":"OHP","DrugName":"MYLERAN TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ALKYLATING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21100010000305","GenericName":"BUSULFAN TAB 2 MG","NDC":"80725062025"},{"Id":419104,"FormularyType":"OHP","DrugName":"TABLOID TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300060000305","GenericName":"THIOGUANINE TAB 40 MG","NDC":"80725063025"},{"Id":419105,"FormularyType":"OHP","DrugName":"DROXIA CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"AGENTS FOR SICKLE CELL DISEASE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82803030000120","GenericName":"HYDROXYUREA CAP 200 MG","NDC":"80725082060"},{"Id":419106,"FormularyType":"OHP","DrugName":"DROXIA CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"AGENTS FOR SICKLE CELL DISEASE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82803030000130","GenericName":"HYDROXYUREA CAP 300 MG","NDC":"80725083060"},{"Id":419107,"FormularyType":"OHP","DrugName":"DROXIA CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"N","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"AGENTS FOR SICKLE CELL DISEASE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82803030000140","GenericName":"HYDROXYUREA CAP 400 MG","NDC":"80725084060"},{"Id":419108,"FormularyType":"OHP","DrugName":"KRAZATI TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532410000320","GenericName":"ADAGRASIB TAB 200 MG","NDC":"80739081218"},{"Id":419109,"FormularyType":"OHP","DrugName":"SPIKEVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E640","GenericName":"COVID-19 MRNA VACCINE-MODERNA IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"80777011201"},{"Id":419110,"FormularyType":"OHP","DrugName":"SPIKEVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E640","GenericName":"COVID-19 MRNA VACCINE-MODERNA IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"80777011288"},{"Id":419111,"FormularyType":"OHP","DrugName":"SPIKEVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E640","GenericName":"COVID-19 MRNA VACCINE-MODERNA IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"80777011296"},{"Id":419112,"FormularyType":"OHP","DrugName":"SPIKEVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"7","AgeMinUnit":"Y","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"1710000240E635","GenericName":"COVID-19 MRNA VAC 6MO-11YR-MODERNA IM SUSP PFS 25 MCG/0.25ML","NDC":"80777011309"},{"Id":419113,"FormularyType":"OHP","DrugName":"SPIKEVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"7","AgeMinUnit":"Y","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"1710000240E635","GenericName":"COVID-19 MRNA VAC 6MO-11YR-MODERNA IM SUSP PFS 25 MCG/0.25ML","NDC":"80777011380"},{"Id":419114,"FormularyType":"OHP","DrugName":"SPIKEVAX INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"7","AgeMinUnit":"Y","AgeMax":"11","AgeMaxUnit":"Y","GenericProductIdentifier":"1710000240E635","GenericName":"COVID-19 MRNA VAC 6MO-11YR-MODERNA IM SUSP PFS 25 MCG/0.25ML","NDC":"80777011387"},{"Id":419115,"FormularyType":"OHP","DrugName":"MRESVIA INJ 50MCG","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710007205E620","GenericName":"RSV MRNA PRE-F VACCINE IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"80777034561"},{"Id":419116,"FormularyType":"OHP","DrugName":"MRESVIA INJ 50MCG","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710007205E620","GenericName":"RSV MRNA PRE-F VACCINE IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"80777034563"},{"Id":419117,"FormularyType":"OHP","DrugName":"MRESVIA INJ 50MCG","DosageForm":"SUSY - Susp Pref Syr","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710007205E620","GenericName":"RSV MRNA PRE-F VACCINE IM SUSP PREF SYR 50 MCG/0.5ML","NDC":"80777034596"},{"Id":419118,"FormularyType":"OHP","DrugName":"MNEXSPIKE INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E637","GenericName":"COVID-19 MRNA VACCINE-MODERNA IM SUSP PREF SYR 10 MCG/0.2ML","NDC":"80777040060"},{"Id":419119,"FormularyType":"OHP","DrugName":"MNEXSPIKE INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E637","GenericName":"COVID-19 MRNA VACCINE-MODERNA IM SUSP PREF SYR 10 MCG/0.2ML","NDC":"80777040061"},{"Id":419120,"FormularyType":"OHP","DrugName":"MNEXSPIKE INJ 2025-26","DosageForm":"SUSY - Susp Pref Syr","Strength":"10","BrandVsGeneric":"N","DrugCategory":"VACCINES","DrugSubClass":"VIRAL VACCINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"12","AgeMinUnit":"Y","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"1710000240E637","GenericName":"COVID-19 MRNA VACCINE-MODERNA IM SUSP PREF SYR 10 MCG/0.2ML","NDC":"80777040062"},{"Id":419121,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000305","GenericName":"ACETAZOLAMIDE TAB 125 MG","NDC":"81005010401"},{"Id":419122,"FormularyType":"OHP","DrugName":"ACETAZOLAMID TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"CARBONIC ANHYDRASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37100010000310","GenericName":"ACETAZOLAMIDE TAB 250 MG","NDC":"81005010501"},{"Id":419123,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000305","GenericName":"METOLAZONE TAB 2.5 MG","NDC":"81005012401"},{"Id":419124,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000310","GenericName":"METOLAZONE TAB 5 MG","NDC":"81005012501"},{"Id":419125,"FormularyType":"OHP","DrugName":"METOLAZONE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"THIAZIDES AND THIAZIDE-LIKE DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37600060000315","GenericName":"METOLAZONE TAB 10 MG","NDC":"81005012601"},{"Id":419126,"FormularyType":"OHP","DrugName":"ACETAMINOPHE SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"81033000250"},{"Id":419127,"FormularyType":"OHP","DrugName":"ACETAMINOPHE SOL 160/5ML","DosageForm":"SOLN - Solution","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010002010","GenericName":"ACETAMINOPHEN SOLN 160 MG/5ML","NDC":"81033000255"},{"Id":419128,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81033000305"},{"Id":419129,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81033000310"},{"Id":419130,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81033000340"},{"Id":419131,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81033000350"},{"Id":419132,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"81033001105"},{"Id":419133,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"81033001150"},{"Id":419134,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81033001805"},{"Id":419135,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 200/10ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81033001810"},{"Id":419136,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81033001850"},{"Id":419137,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 200/10ML","DosageForm":"SUSP - Suspension","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81033001852"},{"Id":419138,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"81033022051"},{"Id":419139,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"81033022052"},{"Id":419140,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"81033051215"},{"Id":419141,"FormularyType":"OHP","DrugName":"CHLORHEX GLU SOL 0.12%","DosageForm":"SOLN - Solution","Strength":"0.12","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTISEPTICS - MOUTH/THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88150020102012","GenericName":"CHLORHEXIDINE GLUCONATE SOLN 0.12%","NDC":"81033051250"},{"Id":419142,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"81131000379"},{"Id":419143,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG CINN","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131000575"},{"Id":419144,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131000576"},{"Id":419145,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"81131000720"},{"Id":419146,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"81131001131"},{"Id":419147,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"81131001132"},{"Id":419148,"FormularyType":"OHP","DrugName":"IBUPROFEN JR CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"81131001659"},{"Id":419149,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"81131001682"},{"Id":419150,"FormularyType":"OHP","DrugName":"RELION PEN MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"81131002313"},{"Id":419151,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"81131002406"},{"Id":419152,"FormularyType":"OHP","DrugName":"ALLERGY REL SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"81131002419"},{"Id":419153,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"81131002705"},{"Id":419154,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"81131002712"},{"Id":419155,"FormularyType":"OHP","DrugName":"EQ 1% HYDROC CRE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"81131002775"},{"Id":419156,"FormularyType":"OHP","DrugName":"EQ TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"81131002776"},{"Id":419157,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"81131003114"},{"Id":419158,"FormularyType":"OHP","DrugName":"EQ ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"81131003457"},{"Id":419159,"FormularyType":"OHP","DrugName":"EQ ALRGY REL TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"81131003482"},{"Id":419160,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131003843"},{"Id":419161,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131003844"},{"Id":419162,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131003845"},{"Id":419163,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131003846"},{"Id":419164,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131003847"},{"Id":419165,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ STRAWBRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131003848"},{"Id":419166,"FormularyType":"OHP","DrugName":"EQ CETIRIZIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"81131003850"},{"Id":419167,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"81131003851"},{"Id":419168,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81131003885"},{"Id":419169,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"81131003921"},{"Id":419170,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"81131003924"},{"Id":419171,"FormularyType":"OHP","DrugName":"EQ HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"81131004036"},{"Id":419172,"FormularyType":"OHP","DrugName":"CA CIT/VIT D TAB 315/250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"81131004597"},{"Id":419173,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"81131004633"},{"Id":419174,"FormularyType":"OHP","DrugName":"CALC CITR+D3 TAB 200-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"81131005586"},{"Id":419175,"FormularyType":"OHP","DrugName":"SV MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"81131005673"},{"Id":419176,"FormularyType":"OHP","DrugName":"PRENAT DHA CHW 0.4-25MG","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78510520000530","GenericName":"*PRENATAL MV & MIN W/ FA-DHA CHEW TAB 0.4-25 MG***","NDC":"81131005686"},{"Id":419177,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"81131005691"},{"Id":419178,"FormularyType":"OHP","DrugName":"GLUCOSE CHW GRAPE","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"81131006033"},{"Id":419179,"FormularyType":"OHP","DrugName":"GLUCOSE CHW FRT PNCH","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27309902400520","GenericName":"GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG","NDC":"81131006034"},{"Id":419180,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"81131006044"},{"Id":419181,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"81131006146"},{"Id":419182,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131006267"},{"Id":419183,"FormularyType":"OHP","DrugName":"NUTR SHAKE + LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131006268"},{"Id":419184,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131006269"},{"Id":419185,"FormularyType":"OHP","DrugName":"NUTRITIONAL LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131006270"},{"Id":419186,"FormularyType":"OHP","DrugName":"EQ SLEEP-AID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"81131006564"},{"Id":419187,"FormularyType":"OHP","DrugName":"EQ CETIRIZIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"81131006566"},{"Id":419188,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"81131006574"},{"Id":419189,"FormularyType":"OHP","DrugName":"EQ LAXATIVE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"81131007125"},{"Id":419190,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"81131007162"},{"Id":419191,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"81131007164"},{"Id":419192,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"81131007165"},{"Id":419193,"FormularyType":"OHP","DrugName":"CALC CITR+D3 TAB 315-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"81131007172"},{"Id":419194,"FormularyType":"OHP","DrugName":"FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"81131007181"},{"Id":419195,"FormularyType":"OHP","DrugName":"SV MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"81131007403"},{"Id":419196,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131007412"},{"Id":419197,"FormularyType":"OHP","DrugName":"EQ HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"81131007414"},{"Id":419198,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131007845"},{"Id":419199,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81131007850"},{"Id":419200,"FormularyType":"OHP","DrugName":"EQ HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"81131007851"},{"Id":419201,"FormularyType":"OHP","DrugName":"SV MELATONIN TAB 3MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007230","GenericName":"MELATONIN TABLET DISINTEGRATING 3 MG","NDC":"81131008747"},{"Id":419202,"FormularyType":"OHP","DrugName":"SV MELATONIN TAB 5MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007250","GenericName":"MELATONIN TABLET DISINTEGRATING 5 MG","NDC":"81131008748"},{"Id":419203,"FormularyType":"OHP","DrugName":"EQ ESOME MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"81131008952"},{"Id":419204,"FormularyType":"OHP","DrugName":"EQ ESOME MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"81131008954"},{"Id":419205,"FormularyType":"OHP","DrugName":"EQ ESOME MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"81131008958"},{"Id":419206,"FormularyType":"OHP","DrugName":"SV IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"81131009371"},{"Id":419207,"FormularyType":"OHP","DrugName":"SV MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"81131009373"},{"Id":419208,"FormularyType":"OHP","DrugName":"EQ ALRGY REL TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"81131009417"},{"Id":419209,"FormularyType":"OHP","DrugName":"SV VITAMIN D CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"81131009537"},{"Id":419210,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"81131009601"},{"Id":419211,"FormularyType":"OHP","DrugName":"EQ MINERAL OIL","DosageForm":"OIL - Oil","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"81131009935"},{"Id":419212,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81131010066"},{"Id":419213,"FormularyType":"OHP","DrugName":"EQ PAIN RELI SUS 160MG/5","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"81131010151"},{"Id":419214,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"81131010669"},{"Id":419215,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"81131010988"},{"Id":419216,"FormularyType":"OHP","DrugName":"EQ LAXATIVE CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"81131011118"},{"Id":419217,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"81131011140"},{"Id":419218,"FormularyType":"OHP","DrugName":"SV B12 SUB 500MCG","DosageForm":"SUBL - Tab Sublingual","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000703","GenericName":"CYANOCOBALAMIN SL TAB 500 MCG","NDC":"81131011187"},{"Id":419219,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"81131011189"},{"Id":419220,"FormularyType":"OHP","DrugName":"EQ PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131011194"},{"Id":419221,"FormularyType":"OHP","DrugName":"EQ PAIN RELI TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131011195"},{"Id":419222,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131011254"},{"Id":419223,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81131011980"},{"Id":419224,"FormularyType":"OHP","DrugName":"EQ ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"81131012220"},{"Id":419225,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"81131012373"},{"Id":419226,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"81131013834"},{"Id":419227,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"81131013835"},{"Id":419228,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"81131013836"},{"Id":419229,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"81131013837"},{"Id":419230,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"81131013838"},{"Id":419231,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"81131013839"},{"Id":419232,"FormularyType":"OHP","DrugName":"EQ TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"81131013842"},{"Id":419233,"FormularyType":"OHP","DrugName":"CASCARA SAGR CAP 450MG","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"N","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200020000125","GenericName":"CASCARA SAGRADA CAP 450 MG","NDC":"81131014500"},{"Id":419234,"FormularyType":"OHP","DrugName":"BUDESONIDE SUS 32MCG","DosageForm":"SUSP - Suspension","Strength":"32","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200015001810","GenericName":"BUDESONIDE NASAL SUSP 32 MCG/ACT","NDC":"81131014776"},{"Id":419235,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG CINN","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"81131014797"},{"Id":419236,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG CINN","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"81131014798"},{"Id":419237,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"81131015008"},{"Id":419238,"FormularyType":"OHP","DrugName":"PAIN & FEVER CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"81131015009"},{"Id":419239,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 1MG/ML","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000940","GenericName":"MELATONIN LIQUID 1 MG/ML","NDC":"81131015112"},{"Id":419240,"FormularyType":"OHP","DrugName":"SV FISH OIL CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"81131015690"},{"Id":419241,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"81131015699"},{"Id":419242,"FormularyType":"OHP","DrugName":"EQ ALLERGY CHW 12.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100510","GenericName":"DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG","NDC":"81131017103"},{"Id":419243,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131017813"},{"Id":419244,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131017814"},{"Id":419245,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG CINN","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131017817"},{"Id":419246,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"81131018379"},{"Id":419247,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"81131018380"},{"Id":419248,"FormularyType":"OHP","DrugName":"EQ ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"81131018387"},{"Id":419249,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81131018393"},{"Id":419250,"FormularyType":"OHP","DrugName":"EQ ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"81131018722"},{"Id":419251,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131018728"},{"Id":419252,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131018730"},{"Id":419253,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131018732"},{"Id":419254,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131018734"},{"Id":419255,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"81131018738"},{"Id":419256,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"81131018739"},{"Id":419257,"FormularyType":"OHP","DrugName":"EQ NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"81131018740"},{"Id":419258,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"81131018748"},{"Id":419259,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131023516"},{"Id":419260,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81131023517"},{"Id":419261,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"81131027537"},{"Id":419262,"FormularyType":"OHP","DrugName":"EQ LORATADIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"81131027666"},{"Id":419263,"FormularyType":"OHP","DrugName":"EQ LORATADIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030007220","GenericName":"LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG","NDC":"81131027671"},{"Id":419264,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131028017"},{"Id":419265,"FormularyType":"OHP","DrugName":"EQ SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"81131028018"},{"Id":419266,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"81131028039"},{"Id":419267,"FormularyType":"OHP","DrugName":"NUTR SHAKE LIQ CHOCOLAT","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"81131028073"},{"Id":419268,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"81131028824"},{"Id":419269,"FormularyType":"OHP","DrugName":"EQ SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"81131028941"},{"Id":419270,"FormularyType":"OHP","DrugName":"EQ LAXATIVE POW 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"81131028951"},{"Id":419271,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"81131029768"},{"Id":419272,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"81131029769"},{"Id":419273,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131029780"},{"Id":419274,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131029781"},{"Id":419275,"FormularyType":"OHP","DrugName":"EQ CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"81131029791"},{"Id":419276,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"81131031164"},{"Id":419277,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"81131031165"},{"Id":419278,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"81131031174"},{"Id":419279,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"81131031175"},{"Id":419280,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"81131031176"},{"Id":419281,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"81131031177"},{"Id":419282,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"81131031178"},{"Id":419283,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"81131031179"},{"Id":419284,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"81131031250"},{"Id":419285,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"81131031255"},{"Id":419286,"FormularyType":"OHP","DrugName":"SALMON OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"81131031264"},{"Id":419287,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"81131031271"},{"Id":419288,"FormularyType":"OHP","DrugName":"D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"81131031282"},{"Id":419289,"FormularyType":"OHP","DrugName":"EQ ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"81131035241"},{"Id":419290,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"81131035329"},{"Id":419291,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"81131035426"},{"Id":419292,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"81131035432"},{"Id":419293,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131035434"},{"Id":419294,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131035435"},{"Id":419295,"FormularyType":"OHP","DrugName":"SINUS 12-HR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"81131035552"},{"Id":419296,"FormularyType":"OHP","DrugName":"SINUS & CONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"81131035553"},{"Id":419297,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"81131035734"},{"Id":419298,"FormularyType":"OHP","DrugName":"EQ ARTHRITIS GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"81131035741"},{"Id":419299,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"81131035742"},{"Id":419300,"FormularyType":"OHP","DrugName":"SINUS & CONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"81131036627"},{"Id":419301,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"81131036639"},{"Id":419302,"FormularyType":"OHP","DrugName":"EQ ALRGY REL TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"81131036640"},{"Id":419303,"FormularyType":"OHP","DrugName":"EQ MICONAZ 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"81131036689"},{"Id":419304,"FormularyType":"OHP","DrugName":"PAIN RELIEVE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131036704"},{"Id":419305,"FormularyType":"OHP","DrugName":"EQ OLOPATADI SOL 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"81131036710"},{"Id":419306,"FormularyType":"OHP","DrugName":"EQ OLOPATADI SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"81131036711"},{"Id":419307,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"81131037868"},{"Id":419308,"FormularyType":"OHP","DrugName":"RELION PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"81131038679"},{"Id":419309,"FormularyType":"OHP","DrugName":"RELION PEN MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"81131038680"},{"Id":419310,"FormularyType":"OHP","DrugName":"RELION PEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"81131038681"},{"Id":419311,"FormularyType":"OHP","DrugName":"EQ SENNA-S TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"81131039561"},{"Id":419312,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"81131039563"},{"Id":419313,"FormularyType":"OHP","DrugName":"EQ STOOL SOF CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"81131039564"},{"Id":419314,"FormularyType":"OHP","DrugName":"EQ FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"81131039567"},{"Id":419315,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"81131039576"},{"Id":419316,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"81131040571"},{"Id":419317,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"81131040572"},{"Id":419318,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"81131040573"},{"Id":419319,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"81131040908"},{"Id":419320,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131041102"},{"Id":419321,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131041103"},{"Id":419322,"FormularyType":"OHP","DrugName":"PAIN RELIEVR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131041104"},{"Id":419323,"FormularyType":"OHP","DrugName":"EQL ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"81131043349"},{"Id":419324,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81131043357"},{"Id":419325,"FormularyType":"OHP","DrugName":"EQ CETIRIZIN SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"81131044778"},{"Id":419326,"FormularyType":"OHP","DrugName":"EQ STOOL SOF CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"81131044789"},{"Id":419327,"FormularyType":"OHP","DrugName":"D3 ADULT CHW 1000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"81131054393"},{"Id":419328,"FormularyType":"OHP","DrugName":"NAT VIT E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000144","GenericName":"VITAMIN E CAP 670 MG (1000 UNIT)","NDC":"81131067885"},{"Id":419329,"FormularyType":"OHP","DrugName":"PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"81131067887"},{"Id":419330,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"81131069708"},{"Id":419331,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131069937"},{"Id":419332,"FormularyType":"OHP","DrugName":"EQ ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"81131069940"},{"Id":419333,"FormularyType":"OHP","DrugName":"EQ ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"81131069947"},{"Id":419334,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81131069957"},{"Id":419335,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81131069958"},{"Id":419336,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"81131069968"},{"Id":419337,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"81131069972"},{"Id":419338,"FormularyType":"OHP","DrugName":"FIBER THERAP TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"81131069995"},{"Id":419339,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131070008"},{"Id":419340,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131070011"},{"Id":419341,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131070012"},{"Id":419342,"FormularyType":"OHP","DrugName":"EQ IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"81131070021"},{"Id":419343,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"81131073171"},{"Id":419344,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"81131073927"},{"Id":419345,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"81131077638"},{"Id":419346,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"81131077639"},{"Id":419347,"FormularyType":"OHP","DrugName":"NAT VEG LAX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"81131077647"},{"Id":419348,"FormularyType":"OHP","DrugName":"EQ CIMETIDIN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200010000305","GenericName":"CIMETIDINE TAB 200 MG","NDC":"81131077650"},{"Id":419349,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81131077915"},{"Id":419350,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131077930"},{"Id":419351,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131077933"},{"Id":419352,"FormularyType":"OHP","DrugName":"ANTIFUNGAL CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"81131081227"},{"Id":419353,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"81131083709"},{"Id":419354,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"81131083716"},{"Id":419355,"FormularyType":"OHP","DrugName":"EQ NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"81131083718"},{"Id":419356,"FormularyType":"OHP","DrugName":"CALCIUM TAB 500+D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"81131083748"},{"Id":419357,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"81131092820"},{"Id":419358,"FormularyType":"OHP","DrugName":"EQ NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"81131092822"},{"Id":419359,"FormularyType":"OHP","DrugName":"ASPIRIN LOW CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"81131092823"},{"Id":419360,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"81131092834"},{"Id":419361,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"81131092887"},{"Id":419362,"FormularyType":"OHP","DrugName":"POT GLUCONAT TAB 595MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"81131092888"},{"Id":419363,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"81284015100"},{"Id":419364,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 2-0.25GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702120","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","NDC":"81284015110"},{"Id":419365,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"81284015200"},{"Id":419366,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"81284015210"},{"Id":419367,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"81284015300"},{"Id":419368,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"81284015310"},{"Id":419369,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 13.5 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702150","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 13.5 GM (12-1.5 GM)","NDC":"81284015400"},{"Id":419370,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 13.5 GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702150","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 13.5 GM (12-1.5 GM)","NDC":"81284015401"},{"Id":419371,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 40.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"81284015500"},{"Id":419372,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 40.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"81284015501"},{"Id":419373,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"81288001801"},{"Id":419374,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000320","GenericName":"ACYCLOVIR TAB 400 MG","NDC":"81288001802"},{"Id":419375,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"81288001901"},{"Id":419376,"FormularyType":"OHP","DrugName":"ACYCLOVIR TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405010000330","GenericName":"ACYCLOVIR TAB 800 MG","NDC":"81288001902"},{"Id":419377,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"81298578101"},{"Id":419378,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"81298578105"},{"Id":419379,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"81298578303"},{"Id":419380,"FormularyType":"OHP","DrugName":"TRIAMCIN ACE INJ 40MG/ML","DosageForm":"SUSP - Suspension","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100050101810","GenericName":"TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML","NDC":"81298578503"},{"Id":419381,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"81298762001"},{"Id":419382,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"81298762003"},{"Id":419383,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"81306041113"},{"Id":419384,"FormularyType":"OHP","DrugName":"PKU 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"81361093460"},{"Id":419385,"FormularyType":"OHP","DrugName":"PKU 3 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"81361093470"},{"Id":419386,"FormularyType":"OHP","DrugName":"OS 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"81361093490"},{"Id":419387,"FormularyType":"OHP","DrugName":"MSUD 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"81361093510"},{"Id":419388,"FormularyType":"OHP","DrugName":"HOM 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"81361093570"},{"Id":419389,"FormularyType":"OHP","DrugName":"UCD 2 POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"81361093610"},{"Id":419390,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"81421002101"},{"Id":419391,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"81421002102"},{"Id":419392,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"81421002103"},{"Id":419393,"FormularyType":"OHP","DrugName":"DULCOLAX SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"81421002105"},{"Id":419394,"FormularyType":"OHP","DrugName":"DULCOLAX SUS 1200MG","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"81421002910"},{"Id":419395,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"81469013990"},{"Id":419396,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"81469014090"},{"Id":419397,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"81469014190"},{"Id":419398,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.25% OP","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102005","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.25%","NDC":"81469020905"},{"Id":419399,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"81469021005"},{"Id":419400,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"81469021010"},{"Id":419401,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 0.5MG","DosageForm":"TABS - Tablet","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000305","GenericName":"BUMETANIDE TAB 0.5 MG","NDC":"81469022101"},{"Id":419402,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"81469022201"},{"Id":419403,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000310","GenericName":"BUMETANIDE TAB 1 MG","NDC":"81469022205"},{"Id":419404,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"81469022301"},{"Id":419405,"FormularyType":"OHP","DrugName":"BUMETANIDE TAB 2MG","DosageForm":"TABS - Tablet","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010000315","GenericName":"BUMETANIDE TAB 2 MG","NDC":"81469022305"},{"Id":419406,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 40MG/4ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"N","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"81483001201"},{"Id":419407,"FormularyType":"OHP","DrugName":"CAPSAID ES CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"81533020015"},{"Id":419408,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"81533030010"},{"Id":419409,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"81533030024"},{"Id":419410,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81533060010"},{"Id":419411,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81533060011"},{"Id":419412,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"81533060030"},{"Id":419413,"FormularyType":"OHP","DrugName":"UREA LOT 40%","DosageForm":"LOTN - Lotion","Strength":"40","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"EMOLLIENT/KERATOLYTIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90660080004140","GenericName":"UREA LOTION 40%","NDC":"81542020108"},{"Id":419414,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 20MG/2ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"81565020102"},{"Id":419415,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81565020301"},{"Id":419416,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81565020302"},{"Id":419417,"FormularyType":"OHP","DrugName":"ALCOHOL PADS PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"81603062510"},{"Id":419418,"FormularyType":"OHP","DrugName":"DROPSAFE SIC MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"81603094205"},{"Id":419419,"FormularyType":"OHP","DrugName":"DROPSAFE SIC MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"81603095905"},{"Id":419420,"FormularyType":"OHP","DrugName":"INSUPEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"81603262010"},{"Id":419421,"FormularyType":"OHP","DrugName":"INSUPEN MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"81603290210"},{"Id":419422,"FormularyType":"OHP","DrugName":"INSUPEN MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"81603299010"},{"Id":419423,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043007530","GenericName":"LEVETIRACETAM TAB ER 24HR 750 MG","NDC":"81665010060"},{"Id":419424,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025000310","GenericName":"ISOSORBIDE MONONITRATE TAB 10 MG","NDC":"81665010210"},{"Id":419425,"FormularyType":"OHP","DrugName":"ISOSORB MONO TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"N","DrugCategory":"ANTIANGINAL AGENTS","DrugSubClass":"NITRATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"32100025000320","GenericName":"ISOSORBIDE MONONITRATE TAB 20 MG","NDC":"81665010310"},{"Id":419426,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000305","GenericName":"ISONIAZID TAB 100 MG","NDC":"81665010710"},{"Id":419427,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"81665010810"},{"Id":419428,"FormularyType":"OHP","DrugName":"ISONIAZID TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTIMYCOBACTERIAL AGENTS","DrugSubClass":"ANTIMYCOBACTERIAL AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"09000060000310","GenericName":"ISONIAZID TAB 300 MG","NDC":"81665010830"},{"Id":419429,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"81665020005"},{"Id":419430,"FormularyType":"OHP","DrugName":"SOD BICARB INJ 8.4%","DosageForm":"SOLN - Solution","Strength":"8.4","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"BICARBONATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79050020002025","GenericName":"SODIUM BICARBONATE IV SOLN 8.4%","NDC":"81665020025"},{"Id":419431,"FormularyType":"OHP","DrugName":"OJJAARA TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537540300340","GenericName":"MOMELOTINIB DIHYDROCHLORIDE TAB 200 MG","NDC":"81864010130"},{"Id":419432,"FormularyType":"OHP","DrugName":"OJJAARA TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537540300330","GenericName":"MOMELOTINIB DIHYDROCHLORIDE TAB 150 MG","NDC":"81864010230"},{"Id":419433,"FormularyType":"OHP","DrugName":"OJJAARA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21537540300320","GenericName":"MOMELOTINIB DIHYDROCHLORIDE TAB 100 MG","NDC":"81864010330"},{"Id":419434,"FormularyType":"OHP","DrugName":"SALICYLIC AC GEL 3%","DosageForm":"GEL - Gel","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004080","GenericName":"SALICYLIC ACID GEL 3%","NDC":"81877072730"},{"Id":419435,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"81952011101"},{"Id":419436,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"81952011106"},{"Id":419437,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81952011201"},{"Id":419438,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81952011204"},{"Id":419439,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81952011205"},{"Id":419440,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81952011206"},{"Id":419441,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81952011209"},{"Id":419442,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 1000/ML","DosageForm":"SOLN - Solution","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202015","GenericName":"HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","NDC":"81952011210"},{"Id":419443,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"81952011301"},{"Id":419444,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"81952011303"},{"Id":419445,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"81952011306"},{"Id":419446,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 10000/ML","DosageForm":"SOLN - Solution","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202035","GenericName":"HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","NDC":"81952011308"},{"Id":419447,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"81952011404"},{"Id":419448,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 5000/ML","DosageForm":"SOLN - Solution","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202025","GenericName":"HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","NDC":"81952011409"},{"Id":419449,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"81952011601"},{"Id":419450,"FormularyType":"OHP","DrugName":"HEPARIN SOD INJ 20000/ML","DosageForm":"SOLN - Solution","Strength":"20000","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"83100020202045","GenericName":"HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","NDC":"81952011606"},{"Id":419451,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"81952012313"},{"Id":419452,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 30/0.3ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E520","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML","NDC":"81952012323"},{"Id":419453,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"81952012414"},{"Id":419454,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E525","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML","NDC":"81952012424"},{"Id":419455,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"81952012616"},{"Id":419456,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 60/0.6ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E530","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML","NDC":"81952012626"},{"Id":419457,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80MG/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"81952012818"},{"Id":419458,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 80MG/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E535","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML","NDC":"81952012828"},{"Id":419459,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"81952013001"},{"Id":419460,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 100MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E540","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML","NDC":"81952013006"},{"Id":419461,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"81952013218"},{"Id":419462,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 120/0.8","DosageForm":"SOSY - Soln Pref Syr","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E560","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML","NDC":"81952013228"},{"Id":419463,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"81952013501"},{"Id":419464,"FormularyType":"OHP","DrugName":"ENOXAPARIN INJ 150MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICOAGULANTS","DrugSubClass":"HEPARINS AND HEPARINOID-LIKE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"8310102010E565","GenericName":"ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML","NDC":"81952013506"},{"Id":419465,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"81964020351"},{"Id":419466,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"81964020354"},{"Id":419467,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 600/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201960","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","NDC":"81964020369"},{"Id":419468,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"81964020407"},{"Id":419469,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"81964020410"},{"Id":419470,"FormularyType":"OHP","DrugName":"AMOX/K CLAV SUS 250/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002201920","GenericName":"AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","NDC":"81964020415"},{"Id":419471,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"81964020501"},{"Id":419472,"FormularyType":"OHP","DrugName":"AMOXICILLIN CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010100110","GenericName":"AMOXICILLIN (TRIHYDRATE) CAP 500 MG","NDC":"81964020505"},{"Id":419473,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"81964020750"},{"Id":419474,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"81964020751"},{"Id":419475,"FormularyType":"OHP","DrugName":"AMOXICILLIN SUS 400/5ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200010101924","GenericName":"AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","NDC":"81964020752"},{"Id":419476,"FormularyType":"OHP","DrugName":"AMOX-POT CLA TAB ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002207420","GenericName":"AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG","NDC":"81964022028"},{"Id":419477,"FormularyType":"OHP","DrugName":"AMOX-POT CLA TAB ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002207420","GenericName":"AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG","NDC":"81964022040"},{"Id":419478,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"81964022101"},{"Id":419479,"FormularyType":"OHP","DrugName":"AMOX/K CLAV TAB 875-125","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002200340","GenericName":"AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","NDC":"81964022114"},{"Id":419480,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"82009000110"},{"Id":419481,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"82009000190"},{"Id":419482,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"82009000210"},{"Id":419483,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"82009000310"},{"Id":419484,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"82009000410"},{"Id":419485,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"82009000610"},{"Id":419486,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"82009000710"},{"Id":419487,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"82009000790"},{"Id":419488,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"82009000805"},{"Id":419489,"FormularyType":"OHP","DrugName":"MONTELUKAST TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIASTHMATIC AND BRONCHODILATOR AGENTS","DrugSubClass":"LEUKOTRIENE MODULATORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"44505050100330","GenericName":"MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","NDC":"82009000910"},{"Id":419490,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 20MG","DosageForm":"TBEC - Tablet DR","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100610","GenericName":"PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","NDC":"82009001090"},{"Id":419491,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"82009001110"},{"Id":419492,"FormularyType":"OHP","DrugName":"PANTOPRAZOLE TAB 40MG","DosageForm":"TBEC - Tablet DR","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270070100620","GenericName":"PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","NDC":"82009001190"},{"Id":419493,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000310","GenericName":"SIMVASTATIN TAB 5 MG","NDC":"82009001210"},{"Id":419494,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000320","GenericName":"SIMVASTATIN TAB 10 MG","NDC":"82009001310"},{"Id":419495,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000330","GenericName":"SIMVASTATIN TAB 20 MG","NDC":"82009001410"},{"Id":419496,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000340","GenericName":"SIMVASTATIN TAB 40 MG","NDC":"82009001510"},{"Id":419497,"FormularyType":"OHP","DrugName":"SIMVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400075000360","GenericName":"SIMVASTATIN TAB 80 MG","NDC":"82009001605"},{"Id":419498,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"82009001710"},{"Id":419499,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100305","GenericName":"ROSUVASTATIN CALCIUM TAB 5 MG","NDC":"82009001790"},{"Id":419500,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"82009001810"},{"Id":419501,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100310","GenericName":"ROSUVASTATIN CALCIUM TAB 10 MG","NDC":"82009001890"},{"Id":419502,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"82009001910"},{"Id":419503,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100320","GenericName":"ROSUVASTATIN CALCIUM TAB 20 MG","NDC":"82009001990"},{"Id":419504,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"82009002010"},{"Id":419505,"FormularyType":"OHP","DrugName":"ROSUVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400060100340","GenericName":"ROSUVASTATIN CALCIUM TAB 40 MG","NDC":"82009002030"},{"Id":419506,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"82009002105"},{"Id":419507,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"82009002190"},{"Id":419508,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"82009002210"},{"Id":419509,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 40MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006530","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 40 MG","NDC":"82009002305"},{"Id":419510,"FormularyType":"OHP","DrugName":"EZETIMIBE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39300030000320","GenericName":"EZETIMIBE TAB 10 MG","NDC":"82009002405"},{"Id":419511,"FormularyType":"OHP","DrugName":"TAMSULOSIN CAP 0.4MG","DosageForm":"CAPS - Capsule","Strength":"0.4","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56852070100110","GenericName":"TAMSULOSIN HCL CAP 0.4 MG","NDC":"82009002510"},{"Id":419512,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100320","GenericName":"AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","NDC":"82009002610"},{"Id":419513,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100330","GenericName":"AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","NDC":"82009002710"},{"Id":419514,"FormularyType":"OHP","DrugName":"AMLODIPINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CALCIUM CHANNEL BLOCKERS","DrugSubClass":"CALCIUM CHANNEL BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"34000003100340","GenericName":"AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","NDC":"82009002810"},{"Id":419515,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"82009003310"},{"Id":419516,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"82009003410"},{"Id":419517,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 40MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106540","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","NDC":"82009003490"},{"Id":419518,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"82009003905"},{"Id":419519,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100310","GenericName":"VALACYCLOVIR HCL TAB 500 MG","NDC":"82009004090"},{"Id":419520,"FormularyType":"OHP","DrugName":"VALACYCLOVIR TAB 1GM","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"HERPES AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12405085100320","GenericName":"VALACYCLOVIR HCL TAB 1 GM","NDC":"82009004190"},{"Id":419521,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200320","GenericName":"LOSARTAN POTASSIUM TAB 25 MG","NDC":"82009004210"},{"Id":419522,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200330","GenericName":"LOSARTAN POTASSIUM TAB 50 MG","NDC":"82009004310"},{"Id":419523,"FormularyType":"OHP","DrugName":"LOSARTAN POT TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150040200340","GenericName":"LOSARTAN POTASSIUM TAB 100 MG","NDC":"82009004410"},{"Id":419524,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"82009004505"},{"Id":419525,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"82009004610"},{"Id":419526,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"82009004710"},{"Id":419527,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"82009005401"},{"Id":419528,"FormularyType":"OHP","DrugName":"FENOFIBRATE TAB 145MG","DosageForm":"TABS - Tablet","Strength":"145","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"FIBRIC ACID DERIVATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39200025000323","GenericName":"FENOFIBRATE TAB 145 MG","NDC":"82009006090"},{"Id":419529,"FormularyType":"OHP","DrugName":"FINASTERIDE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"PROSTATIC HYPERTROPHY AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56851030000320","GenericName":"FINASTERIDE TAB 5 MG","NDC":"82009006105"},{"Id":419530,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000303","GenericName":"LISINOPRIL TAB 2.5 MG","NDC":"82009006205"},{"Id":419531,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000305","GenericName":"LISINOPRIL TAB 5 MG","NDC":"82009006310"},{"Id":419532,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000310","GenericName":"LISINOPRIL TAB 10 MG","NDC":"82009006410"},{"Id":419533,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000315","GenericName":"LISINOPRIL TAB 20 MG","NDC":"82009006510"},{"Id":419534,"FormularyType":"OHP","DrugName":"LISINOPRIL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ACE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36100030000330","GenericName":"LISINOPRIL TAB 40 MG","NDC":"82009006610"},{"Id":419535,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"82009006805"},{"Id":419536,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"82009006905"},{"Id":419537,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"82009007105"},{"Id":419538,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"82009007205"},{"Id":419539,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200320","GenericName":"OLMESARTAN MEDOXOMIL TAB 5 MG","NDC":"82009007390"},{"Id":419540,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200340","GenericName":"OLMESARTAN MEDOXOMIL TAB 20 MG","NDC":"82009007490"},{"Id":419541,"FormularyType":"OHP","DrugName":"OLMESA MEDOX TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERTENSIVES","DrugSubClass":"ANGIOTENSIN II RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"36150055200360","GenericName":"OLMESARTAN MEDOXOMIL TAB 40 MG","NDC":"82009007590"},{"Id":419542,"FormularyType":"OHP","DrugName":"TADALAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143080000320","GenericName":"TADALAFIL TAB 20 MG (PAH)","NDC":"82009008060"},{"Id":419543,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100320","GenericName":"IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","NDC":"82009008690"},{"Id":419544,"FormularyType":"OHP","DrugName":"IMATINIB MES TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21531835100340","GenericName":"IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","NDC":"82009008730"},{"Id":419545,"FormularyType":"OHP","DrugName":"SILDENAFIL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40143060100320","GenericName":"SILDENAFIL CITRATE TAB 20 MG","NDC":"82009009490"},{"Id":419546,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100320","GenericName":"PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","NDC":"82009010305"},{"Id":419547,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100330","GenericName":"PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","NDC":"82009010405"},{"Id":419548,"FormularyType":"OHP","DrugName":"PIOGLITAZONE TAB 45MG","DosageForm":"TABS - Tablet","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN SENSITIZING AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27607050100340","GenericName":"PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","NDC":"82009010505"},{"Id":419549,"FormularyType":"OHP","DrugName":"EMTR/TENOFOV TAB 200-300","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTIVIRALS","DrugSubClass":"ANTIRETROVIRALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"12109902300320","GenericName":"EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","NDC":"82009010930"},{"Id":419550,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"82009011212"},{"Id":419551,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 25MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057510","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","NDC":"82009011305"},{"Id":419552,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 50MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057520","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","NDC":"82009011405"},{"Id":419553,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 100MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057530","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","NDC":"82009011505"},{"Id":419554,"FormularyType":"OHP","DrugName":"METOPROL SUC TAB 200MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS CARDIO-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33200030057540","GenericName":"METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","NDC":"82009011605"},{"Id":419555,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"82009011710"},{"Id":419556,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"82009011801"},{"Id":419557,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100310","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 5 MG","NDC":"82009011905"},{"Id":419558,"FormularyType":"OHP","DrugName":"DONEPEZIL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"ANTIDEMENTIA AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62051025100320","GenericName":"DONEPEZIL HYDROCHLORIDE TAB 10 MG","NDC":"82009012005"},{"Id":419559,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000320","GenericName":"LEVETIRACETAM TAB 250 MG","NDC":"82009012105"},{"Id":419560,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000330","GenericName":"LEVETIRACETAM TAB 500 MG","NDC":"82009012205"},{"Id":419561,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 750MG","DosageForm":"TABS - Tablet","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000340","GenericName":"LEVETIRACETAM TAB 750 MG","NDC":"82009012305"},{"Id":419562,"FormularyType":"OHP","DrugName":"LEVETIRACETA TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600043000350","GenericName":"LEVETIRACETAM TAB 1000 MG","NDC":"82009012460"},{"Id":419563,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 3.125MG","DosageForm":"TABS - Tablet","Strength":"3.125","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000305","GenericName":"CARVEDILOL TAB 3.125 MG","NDC":"82009012505"},{"Id":419564,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 6.25MG","DosageForm":"TABS - Tablet","Strength":"6.25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000310","GenericName":"CARVEDILOL TAB 6.25 MG","NDC":"82009012605"},{"Id":419565,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 12.5MG","DosageForm":"TABS - Tablet","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000320","GenericName":"CARVEDILOL TAB 12.5 MG","NDC":"82009012705"},{"Id":419566,"FormularyType":"OHP","DrugName":"CARVEDILOL TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"ALPHA-BETA BLOCKERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33300007000330","GenericName":"CARVEDILOL TAB 25 MG","NDC":"82009012805"},{"Id":419567,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 7.5MG","DosageForm":"TABS - Tablet","Strength":"7.5","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000320","GenericName":"MELOXICAM TAB 7.5 MG","NDC":"82009012905"},{"Id":419568,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"82009013005"},{"Id":419569,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000310","GenericName":"TOPIRAMATE TAB 25 MG","NDC":"82009013505"},{"Id":419570,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000320","GenericName":"TOPIRAMATE TAB 50 MG","NDC":"82009013605"},{"Id":419571,"FormularyType":"OHP","DrugName":"TOPIRAMATE TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600075000330","GenericName":"TOPIRAMATE TAB 100 MG","NDC":"82009013705"},{"Id":419572,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"82009013860"},{"Id":419573,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"82009013912"},{"Id":419574,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"82009014060"},{"Id":419575,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000310","GenericName":"AMBRISENTAN TAB 5 MG","NDC":"82009014130"},{"Id":419576,"FormularyType":"OHP","DrugName":"AMBRISENTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40160007000320","GenericName":"AMBRISENTAN TAB 10 MG","NDC":"82009014230"},{"Id":419577,"FormularyType":"OHP","DrugName":"FINGOLIMOD CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62407025100120","GenericName":"FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","NDC":"82009014330"},{"Id":419578,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"82009016401"},{"Id":419579,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"82009016501"},{"Id":419580,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"82009017410"},{"Id":419581,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"82009017510"},{"Id":419582,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100310","GenericName":"ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","NDC":"82009017610"},{"Id":419583,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100320","GenericName":"ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","NDC":"82009017710"},{"Id":419584,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100330","GenericName":"ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","NDC":"82009017810"},{"Id":419585,"FormularyType":"OHP","DrugName":"ATORVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400010100350","GenericName":"ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","NDC":"82009017910"},{"Id":419586,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007520","GenericName":"METFORMIN HCL TAB ER 24HR 500 MG","NDC":"82009018005"},{"Id":419587,"FormularyType":"OHP","DrugName":"METFORMIN TAB 750MG ER","DosageForm":"TB24 - Tablet ER 24HR","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050007530","GenericName":"METFORMIN HCL TAB ER 24HR 750 MG","NDC":"82009018101"},{"Id":419588,"FormularyType":"OHP","DrugName":"CLOPIDOGREL TAB 75MG","DosageForm":"TABS - Tablet","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"HEMATOLOGICAL AGENTS - MISC.","DrugSubClass":"PLATELET AGGREGATION INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"85158020100320","GenericName":"CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","NDC":"82009018205"},{"Id":419589,"FormularyType":"OHP","DrugName":"OMEPRAZOLE CAP 20MG","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270060006520","GenericName":"OMEPRAZOLE CAP DELAYED RELEASE 20 MG","NDC":"82009018310"},{"Id":419590,"FormularyType":"OHP","DrugName":"PUSH 20+ ADV LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"82028000020"},{"Id":419591,"FormularyType":"OHP","DrugName":"PUSH 20+ ADV LIQ BLK CHRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"82028000021"},{"Id":419592,"FormularyType":"OHP","DrugName":"PUSH 20+ ADV LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"82028000022"},{"Id":419593,"FormularyType":"OHP","DrugName":"PUSH 20+ ADV LIQ APPLE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"82028006020"},{"Id":419594,"FormularyType":"OHP","DrugName":"PUSH 20+ ADV LIQ BLK CHRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"82028006021"},{"Id":419595,"FormularyType":"OHP","DrugName":"PUSH 20+ ADV LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"82028006022"},{"Id":419596,"FormularyType":"OHP","DrugName":"FOSFOMYCIN POW 3GM","DosageForm":"PACK - Packet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ANTI-INFECTIVE AGENTS - MISC.","DrugSubClass":"URINARY ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"16800015203020","GenericName":"FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","NDC":"82036427401"},{"Id":419597,"FormularyType":"OHP","DrugName":"RAYA SURE MIS 31GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146354","GenericName":"INSULIN PEN NEEDLE 31 G X 4 MM (1/6\" OR 5/32\")","NDC":"82098000110"},{"Id":419598,"FormularyType":"OHP","DrugName":"RAYA SURE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"82098000210"},{"Id":419599,"FormularyType":"OHP","DrugName":"RAYA SURE MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"82098000310"},{"Id":419600,"FormularyType":"OHP","DrugName":"RAYA SURE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"82098000410"},{"Id":419601,"FormularyType":"OHP","DrugName":"RAYA SURE MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"82098000510"},{"Id":419602,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"82098081410"},{"Id":419603,"FormularyType":"OHP","DrugName":"RUBRACA TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535570200320","GenericName":"RUCAPARIB CAMSYLATE TAB 200 MG (BASE EQUIVALENT)","NDC":"82154078301"},{"Id":419604,"FormularyType":"OHP","DrugName":"RUBRACA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535570200325","GenericName":"RUCAPARIB CAMSYLATE TAB 250 MG (BASE EQUIVALENT)","NDC":"82154078401"},{"Id":419605,"FormularyType":"OHP","DrugName":"RUBRACA TAB 300MG","DosageForm":"TABS - Tablet","Strength":"300","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21535570200330","GenericName":"RUCAPARIB CAMSYLATE TAB 300 MG (BASE EQUIVALENT)","NDC":"82154078501"},{"Id":419606,"FormularyType":"OHP","DrugName":"SUCRALFATE SUS 1GM/10ML","DosageForm":"SUSP - Suspension","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"MISC. ANTI-ULCER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49300010001820","GenericName":"SUCRALFATE SUSP 1 GM/10ML","NDC":"82182010614"},{"Id":419607,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"82182032105"},{"Id":419608,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"82182032110"},{"Id":419609,"FormularyType":"OHP","DrugName":"BRIMONIDINE SOL 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMIC ADRENERGIC AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86602020102005","GenericName":"BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","NDC":"82182032115"},{"Id":419610,"FormularyType":"OHP","DrugName":"ATTRUBY PAK 356MG","DosageForm":"TBPK - Tab Ther Pack","Strength":"356","BrandVsGeneric":"N","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"TRANSTHYRETIN STABILIZERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4055001030B720","GenericName":"ACORAMIDIS HCL TAB PACK 356 MG (712 MG TWICE DAILY)","NDC":"82228071228"},{"Id":419611,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"82249001012"},{"Id":419612,"FormularyType":"OHP","DrugName":"ABIRTEGA TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"82249001112"},{"Id":419613,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000320","GenericName":"CAPECITABINE TAB 150 MG","NDC":"82249020760"},{"Id":419614,"FormularyType":"OHP","DrugName":"CAPECITABINE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTIMETABOLITES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21300005000350","GenericName":"CAPECITABINE TAB 500 MG","NDC":"82249021012"},{"Id":419615,"FormularyType":"OHP","DrugName":"DALFAMPRIDIN TAB 10MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62406030007420","GenericName":"DALFAMPRIDINE TAB ER 12HR 10 MG","NDC":"82249070260"},{"Id":419616,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 120MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006520","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","NDC":"82249074514"},{"Id":419617,"FormularyType":"OHP","DrugName":"DIMETHYL FUM CAP 240MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"MULTIPLE SCLEROSIS AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62405525006540","GenericName":"DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","NDC":"82249074760"},{"Id":419618,"FormularyType":"OHP","DrugName":"ATROPINE SUL SOL 1% OP","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"N","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"CYCLOPLEGIC MYDRIATICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86350010102010","GenericName":"ATROPINE SULFATE OPHTH SOLN 1%","NDC":"82260000101"},{"Id":419619,"FormularyType":"OHP","DrugName":"TIMOLOL MAL SOL 0.5% OP","DosageForm":"SOLN - Solution","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030102010","GenericName":"TIMOLOL MALEATE OPHTH SOLN 0.5%","NDC":"82260081305"},{"Id":419620,"FormularyType":"OHP","DrugName":"TIMOLOL GEL SOL 0.25% OP","DosageForm":"SOLG - Gel Forming Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"BETA-BLOCKERS - OPHTHALMIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86250030107620","GenericName":"TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","NDC":"82260081825"},{"Id":419621,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200320","GenericName":"ABIRATERONE ACETATE TAB 250 MG","NDC":"82293000110"},{"Id":419622,"FormularyType":"OHP","DrugName":"ABIRATERONE TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21406010200330","GenericName":"ABIRATERONE ACETATE TAB 500 MG","NDC":"82293000210"},{"Id":419623,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 2.5MG","DosageForm":"TABS - Tablet","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100320","GenericName":"MIDODRINE HCL TAB 2.5 MG","NDC":"82293000310"},{"Id":419624,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100330","GenericName":"MIDODRINE HCL TAB 5 MG","NDC":"82293000410"},{"Id":419625,"FormularyType":"OHP","DrugName":"MIDODRINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VASOPRESSORS","DrugSubClass":"VASOPRESSORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"38000083100340","GenericName":"MIDODRINE HCL TAB 10 MG","NDC":"82293000510"},{"Id":419626,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 2.5MG","DosageForm":"CAPS - Capsule","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000110","GenericName":"LENALIDOMIDE CAPS 2.5 MG","NDC":"82293000610"},{"Id":419627,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000120","GenericName":"LENALIDOMIDE CAP 5 MG","NDC":"82293000710"},{"Id":419628,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000130","GenericName":"LENALIDOMIDE CAP 10 MG","NDC":"82293000810"},{"Id":419629,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 15MG","DosageForm":"CAPS - Capsule","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000140","GenericName":"LENALIDOMIDE CAP 15 MG","NDC":"82293000910"},{"Id":419630,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 20MG","DosageForm":"CAPS - Capsule","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000145","GenericName":"LENALIDOMIDE CAP 20 MG","NDC":"82293001010"},{"Id":419631,"FormularyType":"OHP","DrugName":"LENALIDOMIDE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOMODULATORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99394050000150","GenericName":"LENALIDOMIDE CAP 25 MG","NDC":"82293001110"},{"Id":419632,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 12.5MG","DosageForm":"CAPS - Capsule","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300120","GenericName":"SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","NDC":"82293001410"},{"Id":419633,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300130","GenericName":"SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","NDC":"82293001510"},{"Id":419634,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 37.5MG","DosageForm":"CAPS - Capsule","Strength":"37.5","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300135","GenericName":"SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","NDC":"82293001610"},{"Id":419635,"FormularyType":"OHP","DrugName":"SUNITINIB CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533070300140","GenericName":"SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","NDC":"82293001710"},{"Id":419636,"FormularyType":"OHP","DrugName":"PAZOPANIB TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533042100320","GenericName":"PAZOPANIB HCL TAB 200 MG (BASE EQUIV)","NDC":"82293002210"},{"Id":419637,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"82293002710"},{"Id":419638,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 24-26MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600320","GenericName":"SACUBITRIL-VALSARTAN TAB 24-26 MG","NDC":"82293002720"},{"Id":419639,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"82293002810"},{"Id":419640,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 49-51MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600330","GenericName":"SACUBITRIL-VALSARTAN TAB 49-51 MG","NDC":"82293002820"},{"Id":419641,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"82293002910"},{"Id":419642,"FormularyType":"OHP","DrugName":"SACUB/VALSAR TAB 97-103MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"CARDIOVASCULAR AGENTS - MISC.","DrugSubClass":"CARDIOVASCULAR AGENTS MISC. - COMBINATIONS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"40992002600340","GenericName":"SACUBITRIL-VALSARTAN TAB 97-103 MG","NDC":"82293002920"},{"Id":419643,"FormularyType":"OHP","DrugName":"OGSIVEO TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532350200330","GenericName":"NIROGACESTAT HYDROBROMIDE TAB 100 MG","NDC":"82448010014"},{"Id":419644,"FormularyType":"OHP","DrugName":"GOMEKLI CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533550000120","GenericName":"MIRDAMETINIB CAP 1 MG","NDC":"82448013042"},{"Id":419645,"FormularyType":"OHP","DrugName":"GOMEKLI TAB 1MG","DosageForm":"TBSO - Tablet Soluble","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533550007320","GenericName":"MIRDAMETINIB TAB FOR ORAL SUSP 1 MG","NDC":"82448013442"},{"Id":419646,"FormularyType":"OHP","DrugName":"GOMEKLI TAB 1MG","DosageForm":"TBSO - Tablet Soluble","Strength":"1","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533550007320","GenericName":"MIRDAMETINIB TAB FOR ORAL SUSP 1 MG","NDC":"82448013484"},{"Id":419647,"FormularyType":"OHP","DrugName":"OGSIVEO TAB 150MG","DosageForm":"TABS - Tablet","Strength":"150","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532350200340","GenericName":"NIROGACESTAT HYDROBROMIDE TAB 150 MG","NDC":"82448015014"},{"Id":419648,"FormularyType":"OHP","DrugName":"GOMEKLI CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533550000130","GenericName":"MIRDAMETINIB CAP 2 MG","NDC":"82448026042"},{"Id":419649,"FormularyType":"OHP","DrugName":"GOMEKLI CAP 2MG","DosageForm":"CAPS - Capsule","Strength":"2","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533550000130","GenericName":"MIRDAMETINIB CAP 2 MG","NDC":"82448026084"},{"Id":419650,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"82461031205"},{"Id":419651,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 5% WASH","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000905","GenericName":"BENZOYL PEROXIDE LIQ 5%","NDC":"82461031208"},{"Id":419652,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 10% WASH","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"82461031305"},{"Id":419653,"FormularyType":"OHP","DrugName":"BENZOYL PER LIQ 10% WASH","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050010000910","GenericName":"BENZOYL PEROXIDE LIQ 10%","NDC":"82461031308"},{"Id":419654,"FormularyType":"OHP","DrugName":"NAPROXEN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100060000315","GenericName":"NAPROXEN TAB 500 MG","NDC":"82461071160"},{"Id":419655,"FormularyType":"OHP","DrugName":"MELOXICAM TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100052000330","GenericName":"MELOXICAM TAB 15 MG","NDC":"82461071230"},{"Id":419656,"FormularyType":"OHP","DrugName":"LANSOPRAZOLE CAP 30MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270040006520","GenericName":"LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","NDC":"82461071330"},{"Id":419657,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100303","GenericName":"CYCLOBENZAPRINE HCL TAB 5 MG","NDC":"82461071490"},{"Id":419658,"FormularyType":"OHP","DrugName":"CYCLOBENZAPR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100050100305","GenericName":"CYCLOBENZAPRINE HCL TAB 10 MG","NDC":"82461071690"},{"Id":419659,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"82568000101"},{"Id":419660,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"82568000102"},{"Id":419661,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"82568000103"},{"Id":419662,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"82568000201"},{"Id":419663,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"82568000202"},{"Id":419664,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"82568000301"},{"Id":419665,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"82568000302"},{"Id":419666,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"82568000401"},{"Id":419667,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"82568000402"},{"Id":419668,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"82568000501"},{"Id":419669,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100110","GenericName":"DIPHENHYDRAMINE HCL CAP 50 MG","NDC":"82568000502"},{"Id":419670,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"82568000601"},{"Id":419671,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"82568000602"},{"Id":419672,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"82568000603"},{"Id":419673,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"82568000804"},{"Id":419674,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"82568000806"},{"Id":419675,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"82568000808"},{"Id":419676,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"82568000904"},{"Id":419677,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"82568000906"},{"Id":419678,"FormularyType":"OHP","DrugName":"ACETAMIN LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"82568000908"},{"Id":419679,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"82568001004"},{"Id":419680,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"82568001006"},{"Id":419681,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"82568001008"},{"Id":419682,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"82568001104"},{"Id":419683,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"82568001106"},{"Id":419684,"FormularyType":"OHP","DrugName":"ACETAMINOPHN SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"82568001108"},{"Id":419685,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"82568001604"},{"Id":419686,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"82568001606"},{"Id":419687,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"82568001608"},{"Id":419688,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8/5ML","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"82568002408"},{"Id":419689,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"82568005101"},{"Id":419690,"FormularyType":"OHP","DrugName":"REZDIFFRA TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"HEPATOTROPICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52601060000320","GenericName":"RESMETIROM 60 MG TAB","NDC":"82576006030"},{"Id":419691,"FormularyType":"OHP","DrugName":"REZDIFFRA TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"HEPATOTROPICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52601060000330","GenericName":"RESMETIROM 80 MG TAB","NDC":"82576008030"},{"Id":419692,"FormularyType":"OHP","DrugName":"REZDIFFRA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"HEPATOTROPICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52601060000340","GenericName":"RESMETIROM 100 MG TAB","NDC":"82576010030"},{"Id":419693,"FormularyType":"OHP","DrugName":"FLOWFLEX KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"82607066026"},{"Id":419694,"FormularyType":"OHP","DrugName":"FLOWFLEX KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"82607066027"},{"Id":419695,"FormularyType":"OHP","DrugName":"FLOWFLEX KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"82607066028"},{"Id":419696,"FormularyType":"OHP","DrugName":"FLOWFLEX KIT TEST","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"82607066047"},{"Id":419697,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"82619011104"},{"Id":419698,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100310","GenericName":"RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","NDC":"82619011105"},{"Id":419699,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"82619011204"},{"Id":419700,"FormularyType":"OHP","DrugName":"RIZATRIPTAN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MIGRAINE PRODUCTS","DrugSubClass":"SEROTONIN AGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"67406060100320","GenericName":"RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","NDC":"82619011205"},{"Id":419701,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000110","GenericName":"PREGABALIN CAP 25 MG","NDC":"82619012201"},{"Id":419702,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000115","GenericName":"PREGABALIN CAP 50 MG","NDC":"82619012301"},{"Id":419703,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 75MG","DosageForm":"CAPS - Capsule","Strength":"75","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000120","GenericName":"PREGABALIN CAP 75 MG","NDC":"82619012401"},{"Id":419704,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000125","GenericName":"PREGABALIN CAP 100 MG","NDC":"82619012501"},{"Id":419705,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 150MG","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000135","GenericName":"PREGABALIN CAP 150 MG","NDC":"82619012601"},{"Id":419706,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000145","GenericName":"PREGABALIN CAP 200 MG","NDC":"82619012701"},{"Id":419707,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 225MG","DosageForm":"CAPS - Capsule","Strength":"225","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000150","GenericName":"PREGABALIN CAP 225 MG","NDC":"82619012801"},{"Id":419708,"FormularyType":"OHP","DrugName":"PREGABALIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600057000160","GenericName":"PREGABALIN CAP 300 MG","NDC":"82619012901"},{"Id":419709,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"82619013101"},{"Id":419710,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"82619013102"},{"Id":419711,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"82619014501"},{"Id":419712,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"82619014502"},{"Id":419713,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"82619014601"},{"Id":419714,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"82619014602"},{"Id":419715,"FormularyType":"OHP","DrugName":"FRESKARO SOL MAG CIT","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"82645031010"},{"Id":419716,"FormularyType":"OHP","DrugName":"FRESKARO SOL MAG CIT","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"82645031110"},{"Id":419717,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"82685020101"},{"Id":419718,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.125MG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000305","GenericName":"DIGOXIN TAB 125 MCG (0.125 MG)","NDC":"82685020110"},{"Id":419719,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"82685020201"},{"Id":419720,"FormularyType":"OHP","DrugName":"DIGOXIN TAB 0.25MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"CARDIOTONICS","DrugSubClass":"CARDIAC GLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"31200010000310","GenericName":"DIGOXIN TAB 250 MCG (0.25 MG)","NDC":"82685020210"},{"Id":419721,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"82908041803"},{"Id":419722,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"82908044003"},{"Id":419723,"FormularyType":"OHP","DrugName":"OJEMDA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532075000320","GenericName":"TOVORAFENIB TAB 100 MG","NDC":"82950000116"},{"Id":419724,"FormularyType":"OHP","DrugName":"OJEMDA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532075000320","GenericName":"TOVORAFENIB TAB 100 MG","NDC":"82950000120"},{"Id":419725,"FormularyType":"OHP","DrugName":"OJEMDA TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532075000320","GenericName":"TOVORAFENIB TAB 100 MG","NDC":"82950000124"},{"Id":419726,"FormularyType":"OHP","DrugName":"OJEMDA SUS 25MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532075001920","GenericName":"TOVORAFENIB FOR ORAL SUSP 25 MG/ML","NDC":"82950001201"},{"Id":419727,"FormularyType":"OHP","DrugName":"OJEMDA SUS 25MG/ML","DosageForm":"SUSR - Suspension Reconstituted","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21532075001920","GenericName":"TOVORAFENIB FOR ORAL SUSP 25 MG/ML","NDC":"82950011210"},{"Id":419728,"FormularyType":"OHP","DrugName":"RIVIVE SPR 3/0.1ML","DosageForm":"LIQD - Liquid","Strength":"3","BrandVsGeneric":"N","DrugCategory":"ANTIDOTES AND SPECIFIC ANTAGONISTS","DrugSubClass":"OPIOID ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"93400020100915","GenericName":"NALOXONE HCL NASAL SPRAY 3 MG/0.1ML","NDC":"82954010001"},{"Id":419729,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 0.5MG","DosageForm":"CAPS - Capsule","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000105","GenericName":"TACROLIMUS CAP 0.5 MG","NDC":"82983040010"},{"Id":419730,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 1MG","DosageForm":"CAPS - Capsule","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000110","GenericName":"TACROLIMUS CAP 1 MG","NDC":"82983040110"},{"Id":419731,"FormularyType":"OHP","DrugName":"TACROLIMUS CAP 5MG","DosageForm":"CAPS - Capsule","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MISCELLANEOUS THERAPEUTIC CLASSES","DrugSubClass":"IMMUNOSUPPRESSIVE AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"99404080000120","GenericName":"TACROLIMUS CAP 5 MG","NDC":"82983040210"},{"Id":419732,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 10%","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002085","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","NDC":"82983041147"},{"Id":419733,"FormularyType":"OHP","DrugName":"POT CHLORIDE SOL 20%","DosageForm":"SOLN - Solution","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700030002095","GenericName":"POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","NDC":"82983041247"},{"Id":419734,"FormularyType":"OHP","DrugName":"PHENOBARB SOL 20MG/5ML","DosageForm":"ELIX - Elixir","Strength":"20","BrandVsGeneric":"N","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"BARBITURATE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60100060001010","GenericName":"PHENOBARBITAL ELIXIR 20 MG/5ML","NDC":"82983041747"},{"Id":419735,"FormularyType":"OHP","DrugName":"GABAPENTIN SOL 250/5ML","DosageForm":"SOLN - Solution","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030002020","GenericName":"GABAPENTIN ORAL SOLN 250 MG/5ML","NDC":"82983042347"},{"Id":419736,"FormularyType":"OHP","DrugName":"LACOSAMIDE SOL 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"72600036002060","GenericName":"LACOSAMIDE ORAL SOLUTION 10 MG/ML","NDC":"82983042731"},{"Id":419737,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"83017010903"},{"Id":419738,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"83017011903"},{"Id":419739,"FormularyType":"OHP","DrugName":"EMBECTA NANO MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"83017012203"},{"Id":419740,"FormularyType":"OHP","DrugName":"EMBECTA NANO MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"83017055003"},{"Id":419741,"FormularyType":"OHP","DrugName":"EMBECTA NANO MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"83017057403"},{"Id":419742,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"83017074903"},{"Id":419743,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"83017088003"},{"Id":419744,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"83017088103"},{"Id":419745,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"83017088203"},{"Id":419746,"FormularyType":"OHP","DrugName":"EMBECTA NANO MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"83017088303"},{"Id":419747,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"83017490603"},{"Id":419748,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"83017490703"},{"Id":419749,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"83017490803"},{"Id":419750,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"83017490901"},{"Id":419751,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"83017490903"},{"Id":419752,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"83017491001"},{"Id":419753,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"83017491003"},{"Id":419754,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"83017491101"},{"Id":419755,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"83017491103"},{"Id":419756,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"83017491201"},{"Id":419757,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"83017491203"},{"Id":419758,"FormularyType":"OHP","DrugName":"INS SYR U500 MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030956330","GenericName":"INSULIN SYRINGE/NEEDLE U-500 0.5 ML 31G X 6MM (15/64\")","NDC":"83017673003"},{"Id":419759,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"83017689503"},{"Id":419760,"FormularyType":"OHP","DrugName":"EMBECTA UF MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"83017820303"},{"Id":419761,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"83017827803"},{"Id":419762,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"83017827903"},{"Id":419763,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"83017828003"},{"Id":419764,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"83017828903"},{"Id":419765,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"83017829003"},{"Id":419766,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"83017829103"},{"Id":419767,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"83017841101"},{"Id":419768,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"83017841103"},{"Id":419769,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"83017841801"},{"Id":419770,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"83017841803"},{"Id":419771,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"83017843101"},{"Id":419772,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"83017843103"},{"Id":419773,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"83017843801"},{"Id":419774,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"83017843803"},{"Id":419775,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"83017844001"},{"Id":419776,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"83017844003"},{"Id":419777,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"83017846601"},{"Id":419778,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"83017846603"},{"Id":419779,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"83017846801"},{"Id":419780,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"83017846803"},{"Id":419781,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"83017941003"},{"Id":419782,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906360","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 5/8\"","NDC":"83017941203"},{"Id":419783,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"83017942003"},{"Id":419784,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"83017942403"},{"Id":419785,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"83017946103"},{"Id":419786,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"83017946503"},{"Id":419787,"FormularyType":"OHP","DrugName":"EMBECTA AUTO MIS DUO","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"83017951503"},{"Id":419788,"FormularyType":"OHP","DrugName":"TRUELYTE SOL","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"83035171005"},{"Id":419789,"FormularyType":"OHP","DrugName":"CALC+VIT D3 TAB 500-5","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640335","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-5 MCG(200 UNIT)","NDC":"83035181006"},{"Id":419790,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"83035181205"},{"Id":419791,"FormularyType":"OHP","DrugName":"UTRA CALCIUM TAB + VIT D3","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"83035181406"},{"Id":419792,"FormularyType":"OHP","DrugName":"TRUE VIT B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"83035182001"},{"Id":419793,"FormularyType":"OHP","DrugName":"TRUE VIT B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"83035182005"},{"Id":419794,"FormularyType":"OHP","DrugName":"TRUE VIT B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"83035182101"},{"Id":419795,"FormularyType":"OHP","DrugName":"TRUE VIT B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"83035182105"},{"Id":419796,"FormularyType":"OHP","DrugName":"TRUE MAG OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"83035182201"},{"Id":419797,"FormularyType":"OHP","DrugName":"TRUE MAG OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"83035182205"},{"Id":419798,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"83035182401"},{"Id":419799,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"83035182405"},{"Id":419800,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"83035182501"},{"Id":419801,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"83035182505"},{"Id":419802,"FormularyType":"OHP","DrugName":"TRUE VIT B1 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200310","GenericName":"THIAMINE MONONITRATE TAB 50 MG","NDC":"83035183301"},{"Id":419803,"FormularyType":"OHP","DrugName":"TRUE VIT B1 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"N","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200310","GenericName":"THIAMINE MONONITRATE TAB 50 MG","NDC":"83035183305"},{"Id":419804,"FormularyType":"OHP","DrugName":"TRUE VIT B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"83035183401"},{"Id":419805,"FormularyType":"OHP","DrugName":"TRUE VIT B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"83035183405"},{"Id":419806,"FormularyType":"OHP","DrugName":"TRUE VIT B1 TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200330","GenericName":"THIAMINE MONONITRATE TAB 250 MG","NDC":"83035183501"},{"Id":419807,"FormularyType":"OHP","DrugName":"TRUE VIT D3 TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"83035184101"},{"Id":419808,"FormularyType":"OHP","DrugName":"TRUE VIT D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"83035184201"},{"Id":419809,"FormularyType":"OHP","DrugName":"TRUE VIT D3 TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"83035184301"},{"Id":419810,"FormularyType":"OHP","DrugName":"TRUE VIT D3 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"83035184401"},{"Id":419811,"FormularyType":"OHP","DrugName":"TRUE VIT D3 TAB 1250MCG","DosageForm":"TABS - Tablet","Strength":"1.25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000370","GenericName":"CHOLECALCIFEROL TAB 1.25 MG (50000 UNIT)","NDC":"83035184501"},{"Id":419812,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 10MCG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"83035184601"},{"Id":419813,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"83035184701"},{"Id":419814,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"83035184705"},{"Id":419815,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"83035184801"},{"Id":419816,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"83035184805"},{"Id":419817,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"83035184901"},{"Id":419818,"FormularyType":"OHP","DrugName":"TRUE VIT B3 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000320","GenericName":"NIACIN TAB 50 MG","NDC":"83035185401"},{"Id":419819,"FormularyType":"OHP","DrugName":"TRUE VIT D3 TAB 50MCG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"83035185501"},{"Id":419820,"FormularyType":"OHP","DrugName":"TRUE VIT B3 TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000340","GenericName":"NIACIN TAB 250 MG","NDC":"83035185601"},{"Id":419821,"FormularyType":"OHP","DrugName":"TRUE VIT B3 TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77103010000350","GenericName":"NIACIN TAB 500 MG","NDC":"83035185701"},{"Id":419822,"FormularyType":"OHP","DrugName":"TRUE FER SUL TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"83035185801"},{"Id":419823,"FormularyType":"OHP","DrugName":"TRUE FER SUL TAB 324MG EC","DosageForm":"TBEC - Tablet DR","Strength":"324","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000629","GenericName":"FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)","NDC":"83035185805"},{"Id":419824,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"83035185901"},{"Id":419825,"FormularyType":"OHP","DrugName":"TRUE VIT D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"83035185905"},{"Id":419826,"FormularyType":"OHP","DrugName":"TRUE COVER MIS CONDOM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"83035911201"},{"Id":419827,"FormularyType":"OHP","DrugName":"TRUE COVER MIS CONDOM","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"CONTRACEPTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97401010106200","GenericName":"CONDOMS LATEX LUBRICATED","NDC":"83035911208"},{"Id":419828,"FormularyType":"OHP","DrugName":"ENSACOVE CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533015200120","GenericName":"ENSARTINIB HCL CAP 25 MG (BASE EQUIVALENT)","NDC":"83076102503"},{"Id":419829,"FormularyType":"OHP","DrugName":"ENSACOVE CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533015200140","GenericName":"ENSARTINIB HCL CAP 100 MG (BASE EQUIVALENT)","NDC":"83076110006"},{"Id":419830,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"83090001201"},{"Id":419831,"FormularyType":"OHP","DrugName":"LACOSAMIDE INJ 200/20ML","DosageForm":"SOLN - Solution","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600036002020","GenericName":"LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","NDC":"83090001210"},{"Id":419832,"FormularyType":"OHP","DrugName":"LIDOCAINE SOL 4%","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850060102015","GenericName":"LIDOCAINE HCL SOLN 4%","NDC":"83148004350"},{"Id":419833,"FormularyType":"OHP","DrugName":"GLARGIN YFGN SOL 100U/ML","DosageForm":"SOLN - Solution","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27104003902020","GenericName":"INSULIN GLARGINE-YFGN INJ 100 UNIT/ML","NDC":"83257001411"},{"Id":419834,"FormularyType":"OHP","DrugName":"GLARGIN YFGN INJ 100U/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400390D220","GenericName":"INSULIN GLARGINE-YFGN SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"83257001531"},{"Id":419835,"FormularyType":"OHP","DrugName":"GLARGIN YFGN INJ 100U/ML","DosageForm":"SOPN - Soln Pen-inj","Strength":"100","BrandVsGeneric":"N","DrugCategory":"ANTIDIABETICS","DrugSubClass":"INSULIN","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"2710400390D220","GenericName":"INSULIN GLARGINE-YFGN SOLN PEN-INJECTOR 100 UNIT/ML","NDC":"83257001532"},{"Id":419836,"FormularyType":"OHP","DrugName":"YESINTEK INJ 45/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"45","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025058578E520","GenericName":"USTEKINUMAB-KFCE SOLN PREFILLED SYRINGE 45 MG/0.5ML","NDC":"83257002341"},{"Id":419837,"FormularyType":"OHP","DrugName":"YESINTEK INJ 45/0.5ML","DosageForm":"SOLN - Solution","Strength":"45","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90250585782020","GenericName":"USTEKINUMAB-KFCE SUBCUTANEOUS SOLN 45 MG/0.5ML","NDC":"83257002411"},{"Id":419838,"FormularyType":"OHP","DrugName":"YESINTEK INJ 90MG/ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"90","BrandVsGeneric":"N","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIPSORIATICS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"9025058578E540","GenericName":"USTEKINUMAB-KFCE SOLN PREFILLED SYRINGE 90 MG/ML","NDC":"83257002541"},{"Id":419839,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"83301000101"},{"Id":419840,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000330","GenericName":"GABAPENTIN TAB 600 MG","NDC":"83301000102"},{"Id":419841,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"83301000201"},{"Id":419842,"FormularyType":"OHP","DrugName":"GABAPENTIN TAB 800MG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000340","GenericName":"GABAPENTIN TAB 800 MG","NDC":"83301000202"},{"Id":419843,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"83301000301"},{"Id":419844,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"83301000302"},{"Id":419845,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000110","GenericName":"GABAPENTIN CAP 100 MG","NDC":"83301000303"},{"Id":419846,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"83301000401"},{"Id":419847,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"83301000402"},{"Id":419848,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000130","GenericName":"GABAPENTIN CAP 300 MG","NDC":"83301000403"},{"Id":419849,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"83301000501"},{"Id":419850,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"83301000502"},{"Id":419851,"FormularyType":"OHP","DrugName":"GABAPENTIN CAP 400MG","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTICONVULSANTS","DrugSubClass":"ANTICONVULSANTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"72600030000140","GenericName":"GABAPENTIN CAP 400 MG","NDC":"83301000503"},{"Id":419852,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"83301000801"},{"Id":419853,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"83301000802"},{"Id":419854,"FormularyType":"OHP","DrugName":"METFORMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000320","GenericName":"METFORMIN HCL TAB 500 MG","NDC":"83301000803"},{"Id":419855,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"83301000901"},{"Id":419856,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"83301000902"},{"Id":419857,"FormularyType":"OHP","DrugName":"METFORMIN TAB 850MG","DosageForm":"TABS - Tablet","Strength":"850","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000340","GenericName":"METFORMIN HCL TAB 850 MG","NDC":"83301000903"},{"Id":419858,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"83301001001"},{"Id":419859,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"83301001002"},{"Id":419860,"FormularyType":"OHP","DrugName":"METFORMIN TAB 1000MG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"BIGUANIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27250050000350","GenericName":"METFORMIN HCL TAB 1000 MG","NDC":"83301001003"},{"Id":419861,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"83301001101"},{"Id":419862,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000120","GenericName":"CELECOXIB CAP 100 MG","NDC":"83301001102"},{"Id":419863,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"83301001201"},{"Id":419864,"FormularyType":"OHP","DrugName":"CELECOXIB CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100525000130","GenericName":"CELECOXIB CAP 200 MG","NDC":"83301001202"},{"Id":419865,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"83301002201"},{"Id":419866,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 500/2ML","DosageForm":"SOLN - Solution","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102011","GenericName":"AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","NDC":"83301002202"},{"Id":419867,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"83301002301"},{"Id":419868,"FormularyType":"OHP","DrugName":"AMIKACIN INJ 1GM/4ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"AMINOGLYCOSIDES","DrugSubClass":"AMINOGLYCOSIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"07000010102013","GenericName":"AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","NDC":"83301002302"},{"Id":419869,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 1MG/4ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"83301008002"},{"Id":419870,"FormularyType":"OHP","DrugName":"BUMETANIDE INJ 2.5/10ML","DosageForm":"SOLN - Solution","Strength":"0.25","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200010002005","GenericName":"BUMETANIDE INJ 0.25 MG/ML","NDC":"83301008102"},{"Id":419871,"FormularyType":"OHP","DrugName":"QC IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"83324000530"},{"Id":419872,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"83324000912"},{"Id":419873,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"83324000924"},{"Id":419874,"FormularyType":"OHP","DrugName":"QC IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"83324001204"},{"Id":419875,"FormularyType":"OHP","DrugName":"QC IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"83324001304"},{"Id":419876,"FormularyType":"OHP","DrugName":"QC IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"83324001404"},{"Id":419877,"FormularyType":"OHP","DrugName":"QC LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"83324003330"},{"Id":419878,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"83324003404"},{"Id":419879,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"83324003601"},{"Id":419880,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"83324004001"},{"Id":419881,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"83324004101"},{"Id":419882,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"83324004701"},{"Id":419883,"FormularyType":"OHP","DrugName":"QC TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"83324005001"},{"Id":419884,"FormularyType":"OHP","DrugName":"QC TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"83324005005"},{"Id":419885,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"83324005624"},{"Id":419886,"FormularyType":"OHP","DrugName":"ENTERIC ASA TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"83324005801"},{"Id":419887,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"83324005924"},{"Id":419888,"FormularyType":"OHP","DrugName":"STOMACH RELF TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"83324006040"},{"Id":419889,"FormularyType":"OHP","DrugName":"QC LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"83324006130"},{"Id":419890,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"83324006601"},{"Id":419891,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"83324006824"},{"Id":419892,"FormularyType":"OHP","DrugName":"QC ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"83324007536"},{"Id":419893,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"83324007601"},{"Id":419894,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"83324007801"},{"Id":419895,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"83324007950"},{"Id":419896,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"83324008001"},{"Id":419897,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"83324008101"},{"Id":419898,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"83324008110"},{"Id":419899,"FormularyType":"OHP","DrugName":"QC 8 HR PAIN TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"83324008250"},{"Id":419900,"FormularyType":"OHP","DrugName":"8HR ARTHRITS TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"83324008350"},{"Id":419901,"FormularyType":"OHP","DrugName":"QC ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"83324008701"},{"Id":419902,"FormularyType":"OHP","DrugName":"QC ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"83324008801"},{"Id":419903,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"83324008905"},{"Id":419904,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"83324009036"},{"Id":419905,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"83324009114"},{"Id":419906,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"83324009515"},{"Id":419907,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"83324009530"},{"Id":419908,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"83324010050"},{"Id":419909,"FormularyType":"OHP","DrugName":"QC IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"83324010250"},{"Id":419910,"FormularyType":"OHP","DrugName":"REST SIMPLY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"83324011301"},{"Id":419911,"FormularyType":"OHP","DrugName":"REST SIMPLY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"83324011324"},{"Id":419912,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"83324011625"},{"Id":419913,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"83324011650"},{"Id":419914,"FormularyType":"OHP","DrugName":"QC ANTACID SUS ANTI-GAS","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"83324012112"},{"Id":419915,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"83324013850"},{"Id":419916,"FormularyType":"OHP","DrugName":"QC FAMOTIDIN TAB ACID RED","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"83324013930"},{"Id":419917,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"83324014630"},{"Id":419918,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"83324014710"},{"Id":419919,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"83324016015"},{"Id":419920,"FormularyType":"OHP","DrugName":"PAIN RELIEF SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"83324016104"},{"Id":419921,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"83324017010"},{"Id":419922,"FormularyType":"OHP","DrugName":"ESOMEPRAZOLE CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"83324020014"},{"Id":419923,"FormularyType":"OHP","DrugName":"ESOMEPRAZOLE CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"83324020042"},{"Id":419924,"FormularyType":"OHP","DrugName":"QC ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"83324020501"},{"Id":419925,"FormularyType":"OHP","DrugName":"QC IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"83324020648"},{"Id":419926,"FormularyType":"OHP","DrugName":"QC ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"83324028024"},{"Id":419927,"FormularyType":"OHP","DrugName":"QC T+PLUS SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"83324028608"},{"Id":419928,"FormularyType":"OHP","DrugName":"QC T+PLUS SHA 0.5%","DosageForm":"SHAM - Shampoo","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"TAR PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90520010004505","GenericName":"COAL TAR SHAMPOO 0.5%","NDC":"83324028616"},{"Id":419929,"FormularyType":"OHP","DrugName":"QC ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"83324029245"},{"Id":419930,"FormularyType":"OHP","DrugName":"QC ENEMA ENE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"83324029390"},{"Id":419931,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"83324031396"},{"Id":419932,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"83324031515"},{"Id":419933,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"83324031615"},{"Id":419934,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"83324031772"},{"Id":419935,"FormularyType":"OHP","DrugName":"QC ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"83324031896"},{"Id":419936,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"83324033904"},{"Id":419937,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"83335000112"},{"Id":419938,"FormularyType":"OHP","DrugName":"CURANOL LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"83335010416"},{"Id":419939,"FormularyType":"OHP","DrugName":"ADALIMU-BWWD INJ 40/0.4ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001520E510","GenericName":"ADALIMUMAB-BWWD SOLN PREFILLED SYRINGE 40 MG/0.4ML","NDC":"83457018601"},{"Id":419940,"FormularyType":"OHP","DrugName":"ADALIMU-BWWD INJ 40/0.4ML","DosageForm":"SOAJ - Soln Auto-inj","Strength":"40","BrandVsGeneric":"N","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"6627001520D510","GenericName":"ADALIMUMAB-BWWD SOLN AUTO-INJECTOR 40 MG/0.4ML","NDC":"83457018701"},{"Id":419941,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"83474000104"},{"Id":419942,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"83474000204"},{"Id":419943,"FormularyType":"OHP","DrugName":"SOD CHLORIDE NEB 7%","DosageForm":"NEBU - Nebulization solution","Strength":"7","BrandVsGeneric":"N","DrugCategory":"COUGH/COLD/ALLERGY","DrugSubClass":"MISC. RESPIRATORY INHALANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"43400010002535","GenericName":"SODIUM CHLORIDE SOLN NEBU 7%","NDC":"83490030760"},{"Id":419944,"FormularyType":"OHP","DrugName":"PARI VORTEX MIS ADL MASK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550206300","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","NDC":"83490044061"},{"Id":419945,"FormularyType":"OHP","DrugName":"WELL VITAMIN CAP D3 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"83592001305"},{"Id":419946,"FormularyType":"OHP","DrugName":"WELL VITAMIN CAP D3 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"83592001605"},{"Id":419947,"FormularyType":"OHP","DrugName":"WELL VIT D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"83592007005"},{"Id":419948,"FormularyType":"OHP","DrugName":"WELL MAGNESI TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"83592025905"},{"Id":419949,"FormularyType":"OHP","DrugName":"AMPICILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"AMINOPENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01200020302132","GenericName":"AMPICILLIN SODIUM FOR IV SOLN 10 GM","NDC":"83634010099"},{"Id":419950,"FormularyType":"OHP","DrugName":"NAFCILLIN INJ 10GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLINASE-RESISTANT PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01300040102127","GenericName":"NAFCILLIN SODIUM FOR IV SOLN 10 GM","NDC":"83634010199"},{"Id":419951,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 5MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"5000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102125","GenericName":"PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","NDC":"83634010220"},{"Id":419952,"FormularyType":"OHP","DrugName":"PENICILLN GK INJ 20MU","DosageForm":"SOLR - Solution Reconstituted","Strength":"20000000","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"NATURAL PENICILLINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01100010102135","GenericName":"PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","NDC":"83634010351"},{"Id":419953,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 3-0.375G","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702130","GenericName":"PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","NDC":"83634010530"},{"Id":419954,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"83634010641"},{"Id":419955,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 4-0.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702140","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","NDC":"83634010650"},{"Id":419956,"FormularyType":"OHP","DrugName":"AMP-SULBACTA INJ 15GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252152","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","NDC":"83634010899"},{"Id":419957,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"83634010920"},{"Id":419958,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 1.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252110","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","NDC":"83634010941"},{"Id":419959,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"83634011020"},{"Id":419960,"FormularyType":"OHP","DrugName":"AMP/SULBACTA INJ 3GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002252120","GenericName":"AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","NDC":"83634011041"},{"Id":419961,"FormularyType":"OHP","DrugName":"PIPER/TAZOBA INJ 40.5GM","DosageForm":"SOLR - Solution Reconstituted","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"PENICILLINS","DrugSubClass":"PENICILLIN COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"01990002702170","GenericName":"PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","NDC":"83634011299"},{"Id":419962,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"83634030202"},{"Id":419963,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"83634030204"},{"Id":419964,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"83634030210"},{"Id":419965,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"83634030242"},{"Id":419966,"FormularyType":"OHP","DrugName":"FUROSEMIDE INJ 10MG/ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030002005","GenericName":"FUROSEMIDE INJ 10 MG/ML","NDC":"83634030243"},{"Id":419967,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"83634045101"},{"Id":419968,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"83634045110"},{"Id":419969,"FormularyType":"OHP","DrugName":"DESMOPRESSIN INJ 4MCG/ML","DosageForm":"SOLN - Solution","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"POSTERIOR PITUITARY HORMONES","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"30201010102030","GenericName":"DESMOPRESSIN ACETATE INJ 4 MCG/ML","NDC":"83634045141"},{"Id":419970,"FormularyType":"OHP","DrugName":"LEUPROLIDE KIT 14 DAY","DosageForm":"KIT - Kit","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010106407","GenericName":"LEUPROLIDE ACETATE INJ KIT 1 MG/0.2ML (5 MG/ML)","NDC":"83634045461"},{"Id":419971,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"83634077902"},{"Id":419972,"FormularyType":"OHP","DrugName":"METOCLOPRAM INJ 10MG/2ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020102005","GenericName":"METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","NDC":"83634077941"},{"Id":419973,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"83634078101"},{"Id":419974,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM INJ 50MG/ML","DosageForm":"SOLN - Solution","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030102010","GenericName":"DIPHENHYDRAMINE HCL INJ 50 MG/ML","NDC":"83634078141"},{"Id":419975,"FormularyType":"OHP","DrugName":"PAIN & FEVER LIQ 160/5ML","DosageForm":"LIQD - Liquid","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000912","GenericName":"ACETAMINOPHEN LIQUID 160 MG/5ML","NDC":"83720050016"},{"Id":419976,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"83720050216"},{"Id":419977,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIAMOND","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"83730077478"},{"Id":419978,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIA MD","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"83730079826"},{"Id":419979,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIA LG","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"83730079827"},{"Id":419980,"FormularyType":"OHP","DrugName":"OPTICHAMBER MIS DIAMOND","DosageForm":"DEVI - Device","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"RESPIRATORY THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97100550006200","GenericName":"*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","NDC":"83730079830"},{"Id":419981,"FormularyType":"OHP","DrugName":"NUTRISURE LIQ PLUS VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"83744096291"},{"Id":419982,"FormularyType":"OHP","DrugName":"NUTRISURE LIQ PLUS CHO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"83744096292"},{"Id":419983,"FormularyType":"OHP","DrugName":"NUTRISURE LIQ ORIG VAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"83744096299"},{"Id":419984,"FormularyType":"OHP","DrugName":"NUTRISURE LIQ ORIG CHO","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"83744096300"},{"Id":419985,"FormularyType":"OHP","DrugName":"BRIGHT BEGIN LIQ PEDIATRI","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"83744096434"},{"Id":419986,"FormularyType":"OHP","DrugName":"ELECTROLYTE SOL ADV CARE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"83744096443"},{"Id":419987,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"83745018504"},{"Id":419988,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"83745018508"},{"Id":419989,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"83745018516"},{"Id":419990,"FormularyType":"OHP","DrugName":"CETIRIZINE SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"83745018804"},{"Id":419991,"FormularyType":"OHP","DrugName":"HYDROXYZ HCL SYP 10MG/5ML","DosageForm":"SYRP - Syrup","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIANXIETY AGENTS","DrugSubClass":"ANTIANXIETY AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"57200040101210","GenericName":"HYDROXYZINE HCL SYRUP 10 MG/5ML","NDC":"83745023216"},{"Id":419992,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10GM/15","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"83745024908"},{"Id":419993,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10GM/15","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"83745024916"},{"Id":419994,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10GM/15","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"INTESTINAL ACIDIFIERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52400020002010","GenericName":"LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","NDC":"83745024932"},{"Id":419995,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"83745040508"},{"Id":419996,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"83745040516"},{"Id":419997,"FormularyType":"OHP","DrugName":"LACTULOSE SOL 10/15ML","DosageForm":"SOLN - Solution","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600020002010","GenericName":"LACTULOSE SOLUTION 10 GM/15ML","NDC":"83745040532"},{"Id":419998,"FormularyType":"OHP","DrugName":"LUTRATE DEPO INJ 22.5MG","DosageForm":"INJ - Injectable","Strength":"22.5","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21405010152230","GenericName":"LEUPROLIDE ACETATE (3 MONTH) FOR INJ 22.5 MG","NDC":"83831013401"},{"Id":419999,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"83980000101"},{"Id":420000,"FormularyType":"OHP","DrugName":"HYDROXYCHLOR TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANTIMALARIALS","DrugSubClass":"ANTIMALARIALS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"13000020100305","GenericName":"HYDROXYCHLOROQUINE SULFATE TAB 200 MG","NDC":"83980000105"},{"Id":420001,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"83980000201"},{"Id":420002,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000305","GenericName":"FUROSEMIDE TAB 20 MG","NDC":"83980000210"},{"Id":420003,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"83980000301"},{"Id":420004,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000310","GenericName":"FUROSEMIDE TAB 40 MG","NDC":"83980000310"},{"Id":420005,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"83980000401"},{"Id":420006,"FormularyType":"OHP","DrugName":"FUROSEMIDE TAB 80MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DIURETICS","DrugSubClass":"LOOP DIURETICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"37200030000315","GenericName":"FUROSEMIDE TAB 80 MG","NDC":"83980000405"},{"Id":420007,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"83980000501"},{"Id":420008,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100305","GenericName":"PROPRANOLOL HCL TAB 10 MG","NDC":"83980000510"},{"Id":420009,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"83980000601"},{"Id":420010,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100310","GenericName":"PROPRANOLOL HCL TAB 20 MG","NDC":"83980000610"},{"Id":420011,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"83980000701"},{"Id":420012,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100315","GenericName":"PROPRANOLOL HCL TAB 40 MG","NDC":"83980000710"},{"Id":420013,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100320","GenericName":"PROPRANOLOL HCL TAB 60 MG","NDC":"83980000801"},{"Id":420014,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"83980000901"},{"Id":420015,"FormularyType":"OHP","DrugName":"PROPRANOLOL TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"BETA BLOCKERS","DrugSubClass":"BETA BLOCKERS NON-SELECTIVE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"33100040100325","GenericName":"PROPRANOLOL HCL TAB 80 MG","NDC":"83980000905"},{"Id":420016,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"83980001001"},{"Id":420017,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100303","GenericName":"METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","NDC":"83980001005"},{"Id":420018,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"83980001101"},{"Id":420019,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"83980001105"},{"Id":420020,"FormularyType":"OHP","DrugName":"METOCLOPRAM TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"GASTROINTESTINAL AGENTS - MISC.","DrugSubClass":"GASTROINTESTINAL STIMULANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"52300020100305","GenericName":"METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","NDC":"83980001110"},{"Id":420021,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 4MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007220","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","NDC":"83980001213"},{"Id":420022,"FormularyType":"OHP","DrugName":"ONDANSETRON TAB 8MG ODT","DosageForm":"TBDP - Tablet Disintegrating","Strength":"8","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"5-HT3 RECEPTOR ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50250065007240","GenericName":"ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","NDC":"83980001313"},{"Id":420023,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000120","GenericName":"ETODOLAC CAP 200 MG","NDC":"83980003101"},{"Id":420024,"FormularyType":"OHP","DrugName":"ETODOLAC CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100008000130","GenericName":"ETODOLAC CAP 300 MG","NDC":"83980003201"},{"Id":420025,"FormularyType":"OHP","DrugName":"REDEMPLO SOL 25/0.5ML","DosageForm":"SOSY - Soln Pref Syr","Strength":"25","BrandVsGeneric":"N","DrugCategory":"ENDOCRINE AND METABOLIC AGENTS - MISC.","DrugSubClass":"METABOLIC MODIFIERS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"3090627030E530","GenericName":"PLOZASIRAN SODIUM SUBCUT SOLN PREF SYR 25 MG/0.5ML (BASE EQ)","NDC":"84141002501"},{"Id":420026,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"84386003190"},{"Id":420027,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100320","GenericName":"PRAVASTATIN SODIUM TAB 10 MG","NDC":"84386003199"},{"Id":420028,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"84386003290"},{"Id":420029,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100330","GenericName":"PRAVASTATIN SODIUM TAB 20 MG","NDC":"84386003299"},{"Id":420030,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"84386003390"},{"Id":420031,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 40MG","DosageForm":"TABS - Tablet","Strength":"40","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100340","GenericName":"PRAVASTATIN SODIUM TAB 40 MG","NDC":"84386003399"},{"Id":420032,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"84386003490"},{"Id":420033,"FormularyType":"OHP","DrugName":"PRAVASTATIN TAB 80MG","DosageForm":"TABS - Tablet","Strength":"80","BrandVsGeneric":"Y","DrugCategory":"ANTIHYPERLIPIDEMICS","DrugSubClass":"HMG COA REDUCTASE INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"39400065100360","GenericName":"PRAVASTATIN SODIUM TAB 80 MG","NDC":"84386003499"},{"Id":420034,"FormularyType":"OHP","DrugName":"BACLOFEN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100010000303","GenericName":"BACLOFEN TAB 5 MG","NDC":"84386003501"},{"Id":420035,"FormularyType":"OHP","DrugName":"PERMETHRIN CRE 5%","DosageForm":"CREA - Cream","Strength":"5","BrandVsGeneric":"O","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035003720","GenericName":"PERMETHRIN CREAM 5%","NDC":"84386007360"},{"Id":420036,"FormularyType":"OHP","DrugName":"GNP LAXATIVE TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"84401042968"},{"Id":420037,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"84415001201"},{"Id":420038,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 25/10ML","DosageForm":"LIQD - Liquid","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"84415001301"},{"Id":420039,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"84415001501"},{"Id":420040,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"84415001601"},{"Id":420041,"FormularyType":"OHP","DrugName":"ALUM/MAGNES/ SUS SIMETH","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"84415001701"},{"Id":420042,"FormularyType":"OHP","DrugName":"SENNA SYP 8.8MG/5","DosageForm":"SYRP - Syrup","Strength":"8.8","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060201220","GenericName":"SENNOSIDES SYRUP 8.8 MG/5ML","NDC":"84415002101"},{"Id":420043,"FormularyType":"OHP","DrugName":"FERROUS SULF SOL 300/5ML","DosageForm":"SOLN - Solution","Strength":"300","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002041","GenericName":"FERROUS SULFATE SOLN 300 MG/5ML (60 MG/5ML ELEMENTAL FE)","NDC":"84415002301"},{"Id":420044,"FormularyType":"OHP","DrugName":"GLYCERN CHLD SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"84415004101"},{"Id":420045,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"84415004102"},{"Id":420046,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - MAGNESIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48400020000310","GenericName":"MAGNESIUM OXIDE TAB 400 MG","NDC":"84447000112"},{"Id":420047,"FormularyType":"OHP","DrugName":"SOD CITRATE SOL CITR ACD","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"GENITOURINARY AGENTS - MISCELLANEOUS","DrugSubClass":"ALKALINIZERS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"56202020002010","GenericName":"SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML","NDC":"84447001701"},{"Id":420048,"FormularyType":"OHP","DrugName":"DIPHENHYDRAM LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"84447010316"},{"Id":420049,"FormularyType":"OHP","DrugName":"MAGELLAN SYR MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016340","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 23 X 1\"","NDC":"84521000588"},{"Id":420050,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER-LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"84521001230"},{"Id":420051,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"84521001493"},{"Id":420052,"FormularyType":"OHP","DrugName":"CURITY SPONG PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"84521060510"},{"Id":420053,"FormularyType":"OHP","DrugName":"WEBCOL PREP PAD LARGE","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"84527002060"},{"Id":420054,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"84597029583"},{"Id":420055,"FormularyType":"OHP","DrugName":"IBTROZI CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533875050130","GenericName":"TALETRECTINIB ADIPATE CAP 200 MG","NDC":"84651020030"},{"Id":420056,"FormularyType":"OHP","DrugName":"IBTROZI CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC ENZYME INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21533875050130","GenericName":"TALETRECTINIB ADIPATE CAP 200 MG","NDC":"84651020093"},{"Id":420057,"FormularyType":"OHP","DrugName":"KOMZIFTI CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"N","DrugCategory":"ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","DrugSubClass":"ANTINEOPLASTIC - MENIN INHIBITORS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"21480090000140","GenericName":"ZIFTOMENIB CAP 200 MG","NDC":"84696020090"},{"Id":420058,"FormularyType":"OHP","DrugName":"PENTIPS MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"84703049501"},{"Id":420059,"FormularyType":"OHP","DrugName":"UNIFINE PROT MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"84707083501"},{"Id":420060,"FormularyType":"OHP","DrugName":"UNIFINE PROT MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"84707084501"},{"Id":420061,"FormularyType":"OHP","DrugName":"UNIFINE PROT MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"84707085501"},{"Id":420062,"FormularyType":"OHP","DrugName":"UNIFINE SAFE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"84707094001"},{"Id":420063,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 25MCG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"84781086801"},{"Id":420064,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"84781087201"},{"Id":420065,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"84781088801"},{"Id":420066,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.075%","DosageForm":"CREA - Cream","Strength":"0.075","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003730","GenericName":"CAPSAICIN CREAM 0.075%","NDC":"85231020260"},{"Id":420067,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"85317000474"},{"Id":420068,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"85317000476"},{"Id":420069,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"85317000478"},{"Id":420070,"FormularyType":"OHP","DrugName":"NON-ASPIRIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"85317000482"},{"Id":420071,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"85317000502"},{"Id":420072,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN FRST AID","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"85317000511"},{"Id":420073,"FormularyType":"OHP","DrugName":"ANTI-ITCH CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"85317000517"},{"Id":420074,"FormularyType":"OHP","DrugName":"BACITRACIN OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"85317000520"},{"Id":420075,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"85317000531"},{"Id":420076,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"85317000533"},{"Id":420077,"FormularyType":"OHP","DrugName":"SENNA LAXATI TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"85317000730"},{"Id":420078,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"85317000765"},{"Id":420079,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PAIN RLF","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"85317000832"},{"Id":420080,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"85317000844"},{"Id":420081,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"85317000867"},{"Id":420082,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"85380011290"},{"Id":420083,"FormularyType":"OHP","DrugName":"KETOPROFEN CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"M","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100035000105","GenericName":"KETOPROFEN CAP 50 MG","NDC":"85477011101"},{"Id":420084,"FormularyType":"OHP","DrugName":"RELEVIA TAB 27-1MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"85477050930"},{"Id":420085,"FormularyType":"OHP","DrugName":"MATRONEX TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000324","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***","NDC":"85622020030"},{"Id":420086,"FormularyType":"OHP","DrugName":"NATALCHEW CHW","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000530","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***","NDC":"85622020330"},{"Id":420087,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"85633000401"},{"Id":420088,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"85633001036"},{"Id":420089,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB 600-10","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640354","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 600 MG-10 MCG (400 UNIT)","NDC":"85633001060"},{"Id":420090,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"85633001100"},{"Id":420091,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"85633001101"},{"Id":420092,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"85633001105"},{"Id":420093,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"85633001136"},{"Id":420094,"FormularyType":"OHP","DrugName":"FERROUS SULF TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000630","GenericName":"FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)","NDC":"85633001160"},{"Id":420095,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"85633002000"},{"Id":420096,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"85633002001"},{"Id":420097,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"85633002030"},{"Id":420098,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"85633002036"},{"Id":420099,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"85633002100"},{"Id":420100,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"85633002105"},{"Id":420101,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"85633002130"},{"Id":420102,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"85633002136"},{"Id":420103,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"85633002200"},{"Id":420104,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"85633002201"},{"Id":420105,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"85633002230"},{"Id":420106,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"85633002236"},{"Id":420107,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003000"},{"Id":420108,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003001"},{"Id":420109,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003002"},{"Id":420110,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003003"},{"Id":420111,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003005"},{"Id":420112,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003025"},{"Id":420113,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003030"},{"Id":420114,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003036"},{"Id":420115,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"85633003065"},{"Id":420116,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"85633003200"},{"Id":420117,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"85633003205"},{"Id":420118,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"85633003236"},{"Id":420119,"FormularyType":"OHP","DrugName":"OYSTER SHELL TAB 1250MG","DosageForm":"TABS - Tablet","Strength":"1250","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000345","GenericName":"CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA)","NDC":"85633003260"},{"Id":420120,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"85633004000"},{"Id":420121,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"85633004005"},{"Id":420122,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"85633004012"},{"Id":420123,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"85633004030"},{"Id":420124,"FormularyType":"OHP","DrugName":"MAG OXIDE TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"85633004036"},{"Id":420125,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"85633004100"},{"Id":420126,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"85633004101"},{"Id":420127,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"85633004105"},{"Id":420128,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"85633004124"},{"Id":420129,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"85633004130"},{"Id":420130,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000315","GenericName":"FOLIC ACID TAB 1 MG","NDC":"85633004136"},{"Id":420131,"FormularyType":"OHP","DrugName":"DEXAMETHASON ELX 0.5/5ML","DosageForm":"ELIX - Elixir","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"CORTICOSTEROIDS","DrugSubClass":"GLUCOCORTICOSTEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"22100020001005","GenericName":"DEXAMETHASONE ELIXIR 0.5 MG/5ML","NDC":"85742000403"},{"Id":420132,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"85742001310"},{"Id":420133,"FormularyType":"OHP","DrugName":"NYSTATIN SUS 100000","DosageForm":"SUSP - Suspension","Strength":"100000","BrandVsGeneric":"Y","DrugCategory":"MOUTH/THROAT/DENTAL AGENTS","DrugSubClass":"ANTI-INFECTIVES - THROAT","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"88100010001805","GenericName":"NYSTATIN SUSP 100000 UNIT/ML","NDC":"85742001311"},{"Id":420134,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"86227001015"},{"Id":420135,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227001605"},{"Id":420136,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"86227004015"},{"Id":420137,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"86227004016"},{"Id":420138,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"86227004035"},{"Id":420139,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"86227004055"},{"Id":420140,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"86227004105"},{"Id":420141,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"86227004106"},{"Id":420142,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"86227004205"},{"Id":420143,"FormularyType":"OHP","DrugName":"30ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006330","GenericName":"SYRINGE (DISPOSABLE) 30 ML","NDC":"86227004305"},{"Id":420144,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227004605"},{"Id":420145,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227004606"},{"Id":420146,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 60ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227004655"},{"Id":420147,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"86227005306"},{"Id":420148,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"86227005315"},{"Id":420149,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"86227005316"},{"Id":420150,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"86227005325"},{"Id":420151,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 22G X 1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"86227005355"},{"Id":420152,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"86227005365"},{"Id":420153,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"86227005366"},{"Id":420154,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"86227005375"},{"Id":420155,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"86227005376"},{"Id":420156,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"86227005385"},{"Id":420157,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"86227005386"},{"Id":420158,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"86227005395"},{"Id":420159,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"86227010101"},{"Id":420160,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"86227010105"},{"Id":420161,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"86227011155"},{"Id":420162,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"86227012105"},{"Id":420163,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"86227012125"},{"Id":420164,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"86227012155"},{"Id":420165,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"86227012175"},{"Id":420166,"FormularyType":"OHP","DrugName":"ALCOHOL PAD PREP","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"86227012205"},{"Id":420167,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"86227012605"},{"Id":420168,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"86227013025"},{"Id":420169,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"86227013055"},{"Id":420170,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"86227013085"},{"Id":420171,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227016015"},{"Id":420172,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"86227018001"},{"Id":420173,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"86227018015"},{"Id":420174,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"86227018155"},{"Id":420175,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"86227018525"},{"Id":420176,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"86227019015"},{"Id":420177,"FormularyType":"OHP","DrugName":"POLY HUB MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"86227021015"},{"Id":420178,"FormularyType":"OHP","DrugName":"POLY HUB MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"86227021155"},{"Id":420179,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 26GX3/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016368","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 26 X 3/8\"","NDC":"86227021685"},{"Id":420180,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016387","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2\"","NDC":"86227021755"},{"Id":420181,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"86227021801"},{"Id":420182,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"86227021805"},{"Id":420183,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186320","GenericName":"NEEDLE (DISP) 18 X 1\"","NDC":"86227021806"},{"Id":420184,"FormularyType":"OHP","DrugName":"POLY HUB MIS 18GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020186330","GenericName":"NEEDLE (DISP) 18 X 1-1/2\"","NDC":"86227021815"},{"Id":420185,"FormularyType":"OHP","DrugName":"POLY HUB MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"86227022001"},{"Id":420186,"FormularyType":"OHP","DrugName":"POLY HUB MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020206320","GenericName":"NEEDLE (DISP) 20 X 1\"","NDC":"86227022005"},{"Id":420187,"FormularyType":"OHP","DrugName":"POLY HUB MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"86227022015"},{"Id":420188,"FormularyType":"OHP","DrugName":"POLY HUB MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"86227022101"},{"Id":420189,"FormularyType":"OHP","DrugName":"POLY HUB MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216320","GenericName":"NEEDLE (DISP) 21 X 1\"","NDC":"86227022105"},{"Id":420190,"FormularyType":"OHP","DrugName":"POLY HUB MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020216330","GenericName":"NEEDLE (DISP) 21 X 1-1/2\"","NDC":"86227022115"},{"Id":420191,"FormularyType":"OHP","DrugName":"POLY HUB MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"86227022155"},{"Id":420192,"FormularyType":"OHP","DrugName":"CAREPOINT TU MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040706330","GenericName":"TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"86227022158"},{"Id":420193,"FormularyType":"OHP","DrugName":"POLY HUB MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"86227022201"},{"Id":420194,"FormularyType":"OHP","DrugName":"POLY HUB MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226320","GenericName":"NEEDLE (DISP) 22 X 1\"","NDC":"86227022205"},{"Id":420195,"FormularyType":"OHP","DrugName":"POLY HUB MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020226330","GenericName":"NEEDLE (DISP) 22 X 1-1/2\"","NDC":"86227022215"},{"Id":420196,"FormularyType":"OHP","DrugName":"POLY HUB MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"86227022301"},{"Id":420197,"FormularyType":"OHP","DrugName":"POLY HUB MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"86227022305"},{"Id":420198,"FormularyType":"OHP","DrugName":"POLY HUB MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"86227022306"},{"Id":420199,"FormularyType":"OHP","DrugName":"POLY HUB MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"86227022315"},{"Id":420200,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"86227022501"},{"Id":420201,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"86227022505"},{"Id":420202,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"86227022515"},{"Id":420203,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"86227022516"},{"Id":420204,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"86227022555"},{"Id":420205,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"86227022558"},{"Id":420206,"FormularyType":"OHP","DrugName":"POLY HUB MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"86227022705"},{"Id":420207,"FormularyType":"OHP","DrugName":"POLY HUB MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306305","GenericName":"NEEDLE (DISP) 30 X 1/2\"","NDC":"86227023005"},{"Id":420208,"FormularyType":"OHP","DrugName":"POLY HUB MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"86227023015"},{"Id":420209,"FormularyType":"OHP","DrugName":"POLY HUB MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"86227023155"},{"Id":420210,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"86227025015"},{"Id":420211,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"86227025155"},{"Id":420212,"FormularyType":"OHP","DrugName":"POLY HUB MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"86227025585"},{"Id":420213,"FormularyType":"OHP","DrugName":"POLY HUB MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276305","GenericName":"NEEDLE (DISP) 27 X 1/2\"","NDC":"86227027055"},{"Id":420214,"FormularyType":"OHP","DrugName":"POLY HUB MIS 27GX1.25","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020276325","GenericName":"NEEDLE (DISP) 27 X 1-1/4\"","NDC":"86227027125"},{"Id":420215,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"86227028035"},{"Id":420216,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"86227030035"},{"Id":420217,"FormularyType":"OHP","DrugName":"POLY HUB MIS 30GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020306305","GenericName":"NEEDLE (DISP) 30 X 1/2\"","NDC":"86227030055"},{"Id":420218,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"86227031015"},{"Id":420219,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036325","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1-1/2\"","NDC":"86227031055"},{"Id":420220,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036330","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1\"","NDC":"86227031115"},{"Id":420221,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 21GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036340","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 21 X 1-1/2\"","NDC":"86227031155"},{"Id":420222,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036350","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1\"","NDC":"86227031215"},{"Id":420223,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"86227031255"},{"Id":420224,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"86227031315"},{"Id":420225,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"86227031355"},{"Id":420226,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"86227031515"},{"Id":420227,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"86227031555"},{"Id":420228,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"86227031585"},{"Id":420229,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"86227037055"},{"Id":420230,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"86227039065"},{"Id":420231,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"86227040105"},{"Id":420232,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"86227041035"},{"Id":420233,"FormularyType":"OHP","DrugName":"5ML SYRINGE MIS 20GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040056325","GenericName":"SYRINGE/NEEDLE (DISP) 5 ML 20 X 1-1/2\"","NDC":"86227041055"},{"Id":420234,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227046065"},{"Id":420235,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"86227046125"},{"Id":420236,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 60ML","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227046575"},{"Id":420237,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"86227048125"},{"Id":420238,"FormularyType":"OHP","DrugName":"10ML SYRINGE MIS 21GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040106330","GenericName":"SYRINGE/NEEDLE (DISP) 10 ML 21 X 1\"","NDC":"86227049115"},{"Id":420239,"FormularyType":"OHP","DrugName":"20ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"86227057205"},{"Id":420240,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"86227062035"},{"Id":420241,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"86227062055"},{"Id":420242,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"86227062105"},{"Id":420243,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906334","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4\" (6 MM)","NDC":"86227064035"},{"Id":420244,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906336","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X 1/4\" (6 MM)","NDC":"86227064055"},{"Id":420245,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906337","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 1/4\" (6 MM)","NDC":"86227064105"},{"Id":420246,"FormularyType":"OHP","DrugName":"35ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006335","GenericName":"SYRINGE (DISPOSABLE) 35 ML","NDC":"86227064355"},{"Id":420247,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"86227065035"},{"Id":420248,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"86227065045"},{"Id":420249,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"86227065055"},{"Id":420250,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"86227065105"},{"Id":420251,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"86227070035"},{"Id":420252,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"86227070055"},{"Id":420253,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"86227070105"},{"Id":420254,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016360","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8\"","NDC":"86227071585"},{"Id":420255,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227073605"},{"Id":420256,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER SLP","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227073655"},{"Id":420257,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"86227074015"},{"Id":420258,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX1/4","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"86227074025"},{"Id":420259,"FormularyType":"OHP","DrugName":"60ML SYRINGE MIS LUER LOK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"86227075605"},{"Id":420260,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"86227080055"},{"Id":420261,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"86227080105"},{"Id":420262,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"86227081005"},{"Id":420263,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"86227081015"},{"Id":420264,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 25GX11/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"86227081025"},{"Id":420265,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"86227081035"},{"Id":420266,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 23GX11/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"86227081045"},{"Id":420267,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036370","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 5/8\"","NDC":"86227082005"},{"Id":420268,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036375","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1\"","NDC":"86227082015"},{"Id":420269,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"86227082025"},{"Id":420270,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016365","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 25 X 1\"","NDC":"86227082035"},{"Id":420271,"FormularyType":"OHP","DrugName":"1ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040016340","GenericName":"SYRINGE/NEEDLE (DISP) 1 ML 23 X 1\"","NDC":"86227082045"},{"Id":420272,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 25GX5/8\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256310","GenericName":"NEEDLE (DISP) 25 X 5/8\"","NDC":"86227087005"},{"Id":420273,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"86227087015"},{"Id":420274,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 25GX11/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256330","GenericName":"NEEDLE (DISP) 25 X 1-1/2\"","NDC":"86227087025"},{"Id":420275,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236320","GenericName":"NEEDLE (DISP) 23 X 1\"","NDC":"86227087035"},{"Id":420276,"FormularyType":"OHP","DrugName":"CAREPOINT SA MIS 23GX11/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020236330","GenericName":"NEEDLE (DISP) 23 X 1-1/2\"","NDC":"86227087045"},{"Id":420277,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"86227090035"},{"Id":420278,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"86227090055"},{"Id":420279,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"86227090105"},{"Id":420280,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"86227099005"},{"Id":420281,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"86227099015"},{"Id":420282,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"86227099025"},{"Id":420283,"FormularyType":"OHP","DrugName":"INSULIN SYRI MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"86227099035"},{"Id":420284,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"86227099045"},{"Id":420285,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"86227099055"},{"Id":420286,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"86227099105"},{"Id":420287,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"86227099115"},{"Id":420288,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"86227099125"},{"Id":420289,"FormularyType":"OHP","DrugName":"CAREPOINT SY MIS 23GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036367","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1-1/2\"","NDC":"86227503005"},{"Id":420290,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 20GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036320","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 20 X 1\"","NDC":"86227503015"},{"Id":420291,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 22GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036360","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 22 X 1-1/2\"","NDC":"86227503065"},{"Id":420292,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 23GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036365","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 23 X 1\"","NDC":"86227503075"},{"Id":420293,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS 25GX1.5\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051040036385","GenericName":"SYRINGE/NEEDLE (DISP) 3 ML 25 X 1-1/2\"","NDC":"86227503095"},{"Id":420294,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"86227740105"},{"Id":420295,"FormularyType":"OHP","DrugName":"SURE COMFORT MIS 31GX1/4","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"86227740205"},{"Id":420296,"FormularyType":"OHP","DrugName":"3ML SYRINGE MIS LUER LOC","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"86277040315"},{"Id":420297,"FormularyType":"OHP","DrugName":"SLOW FE TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"86790001930"},{"Id":420298,"FormularyType":"OHP","DrugName":"SLOW FE TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"86790001960"},{"Id":420299,"FormularyType":"OHP","DrugName":"CHLORZOXAZON TAB 250MG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"MUSCULOSKELETAL THERAPY AGENTS","DrugSubClass":"CENTRAL MUSCLE RELAXANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"75100040000305","GenericName":"CHLORZOXAZONE TAB 250 MG","NDC":"87127080160"},{"Id":420300,"FormularyType":"OHP","DrugName":"PILOT COVID KIT HOME TES","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"87473000020"},{"Id":420301,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"87701019024"},{"Id":420302,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"87701019060"},{"Id":420303,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"87701019061"},{"Id":420304,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"87701019062"},{"Id":420305,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"87701019063"},{"Id":420306,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"87701019064"},{"Id":420307,"FormularyType":"OHP","DrugName":"GNP PEN NEED MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"87701019065"},{"Id":420308,"FormularyType":"OHP","DrugName":"GNP MELATONI TAB 12MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"12","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007265","GenericName":"MELATONIN TABLET DISINTEGRATING 12 MG","NDC":"87701019074"},{"Id":420309,"FormularyType":"OHP","DrugName":"PINK BISMUTH TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"87701027262"},{"Id":420310,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701030771"},{"Id":420311,"FormularyType":"OHP","DrugName":"GNP MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"87701030773"},{"Id":420312,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701034277"},{"Id":420313,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701040018"},{"Id":420314,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"87701040272"},{"Id":420315,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701040306"},{"Id":420316,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"87701040316"},{"Id":420317,"FormularyType":"OHP","DrugName":"GNP ALL DAY TAB ALLERGY","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"87701040399"},{"Id":420318,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"87701040471"},{"Id":420319,"FormularyType":"OHP","DrugName":"TERBINAFINE CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"87701040472"},{"Id":420320,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701040485"},{"Id":420321,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701040486"},{"Id":420322,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701040493"},{"Id":420323,"FormularyType":"OHP","DrugName":"GNP ALL DAY TAB ALLERGY","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"87701040503"},{"Id":420324,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"87701040515"},{"Id":420325,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"87701040516"},{"Id":420326,"FormularyType":"OHP","DrugName":"LORATADINE TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"87701040517"},{"Id":420327,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"87701040585"},{"Id":420328,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"87701040586"},{"Id":420329,"FormularyType":"OHP","DrugName":"GNP CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"87701040587"},{"Id":420330,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"87701040608"},{"Id":420331,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701040652"},{"Id":420332,"FormularyType":"OHP","DrugName":"GNP ALL DAY TAB ALLERGY","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"87701040653"},{"Id":420333,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"87701040665"},{"Id":420334,"FormularyType":"OHP","DrugName":"GNP ALCOHOL PAD SWABS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"87701040724"},{"Id":420335,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"87701040729"},{"Id":420336,"FormularyType":"OHP","DrugName":"GNP VIT B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"87701040730"},{"Id":420337,"FormularyType":"OHP","DrugName":"GNP VIT B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"87701040731"},{"Id":420338,"FormularyType":"OHP","DrugName":"GNP VIT B-12 TAB 1000 PR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"87701040732"},{"Id":420339,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"87701040733"},{"Id":420340,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 10MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"87701040748"},{"Id":420341,"FormularyType":"OHP","DrugName":"GNP VIT D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"87701040749"},{"Id":420342,"FormularyType":"OHP","DrugName":"GNP VIT D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"87701040750"},{"Id":420343,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"87701040751"},{"Id":420344,"FormularyType":"OHP","DrugName":"GNP VIT D TAB 5000UNIT","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"87701040752"},{"Id":420345,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"87701040756"},{"Id":420346,"FormularyType":"OHP","DrugName":"GNP VIT E CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"87701040757"},{"Id":420347,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"87701040768"},{"Id":420348,"FormularyType":"OHP","DrugName":"CALCIUM +D3 TAB MAXIMUM","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"87701040773"},{"Id":420349,"FormularyType":"OHP","DrugName":"CALCIUM +D3 TAB MAXIMUM","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660333","GenericName":"CALCIUM CIT-VIT D TAB 315 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"87701040774"},{"Id":420350,"FormularyType":"OHP","DrugName":"GNP IRON TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"87701040776"},{"Id":420351,"FormularyType":"OHP","DrugName":"GNP IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010100320","GenericName":"FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE)","NDC":"87701040777"},{"Id":420352,"FormularyType":"OHP","DrugName":"POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"87701040779"},{"Id":420353,"FormularyType":"OHP","DrugName":"GNP PRENATAL TAB 28-0.8MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"87701040799"},{"Id":420354,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"87701040813"},{"Id":420355,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"87701040814"},{"Id":420356,"FormularyType":"OHP","DrugName":"GNP FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"87701040818"},{"Id":420357,"FormularyType":"OHP","DrugName":"GNP FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"87701040819"},{"Id":420358,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"87701040883"},{"Id":420359,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"87701040884"},{"Id":420360,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"87701041108"},{"Id":420361,"FormularyType":"OHP","DrugName":"LICE TRTMNT LIQ 1%","DosageForm":"LIQD - Liquid","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90900035000910","GenericName":"PERMETHRIN CREME RINSE 1%","NDC":"87701041115"},{"Id":420362,"FormularyType":"OHP","DrugName":"VITAMIN D CHW 400UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000520","GenericName":"CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT)","NDC":"87701041154"},{"Id":420363,"FormularyType":"OHP","DrugName":"GNP MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"87701041175"},{"Id":420364,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"87701041249"},{"Id":420365,"FormularyType":"OHP","DrugName":"GNP D CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"87701041269"},{"Id":420366,"FormularyType":"OHP","DrugName":"GNP ELECTROL SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"87701041275"},{"Id":420367,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"87701041284"},{"Id":420368,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"87701041285"},{"Id":420369,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"87701041327"},{"Id":420370,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"87701041772"},{"Id":420371,"FormularyType":"OHP","DrugName":"GNP GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"87701042510"},{"Id":420372,"FormularyType":"OHP","DrugName":"GNP GLYCERIN SUP 2.1GM","DosageForm":"SUPP - Suppository","Strength":"2.1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005250","GenericName":"GLYCERIN SUPPOS 2.1 GM","NDC":"87701042511"},{"Id":420373,"FormularyType":"OHP","DrugName":"GNP GLYCERIN SUP 1.2GM","DosageForm":"SUPP - Suppository","Strength":"1.2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005209","GenericName":"GLYCERIN SUPPOS 1.2 GM","NDC":"87701042512"},{"Id":420374,"FormularyType":"OHP","DrugName":"GNP ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"87701042521"},{"Id":420375,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"87701042568"},{"Id":420376,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW GRAPE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"87701042598"},{"Id":420377,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW GRAPE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"87701042599"},{"Id":420378,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"87701042600"},{"Id":420379,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW ORANGE","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"87701042601"},{"Id":420380,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW RASPBERY","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"87701042602"},{"Id":420381,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW RASPBERR","DosageForm":"CHEW - Tablet Chewable","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000515","GenericName":"GLUCOSE CHEW TAB 4 GM (ROUNDED)","NDC":"87701042603"},{"Id":420382,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 28GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"87701042608"},{"Id":420383,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"87701042610"},{"Id":420384,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"87701042611"},{"Id":420385,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"87701042612"},{"Id":420386,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"87701042614"},{"Id":420387,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"87701042615"},{"Id":420388,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"87701042616"},{"Id":420389,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"87701042617"},{"Id":420390,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"87701042621"},{"Id":420391,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701042623"},{"Id":420392,"FormularyType":"OHP","DrugName":"MELATONIN SUB 10MG","DosageForm":"SUBL - Tab Sublingual","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000750","GenericName":"MELATONIN SL TAB 10 MG","NDC":"87701042634"},{"Id":420393,"FormularyType":"OHP","DrugName":"GNP MAGNESIU TAB OXIDE","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"87701042635"},{"Id":420394,"FormularyType":"OHP","DrugName":"GNP D3 TAB","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"87701042639"},{"Id":420395,"FormularyType":"OHP","DrugName":"GNP D CHW 2000UNIT","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"87701042640"},{"Id":420396,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701042661"},{"Id":420397,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"87701042706"},{"Id":420398,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"87701042722"},{"Id":420399,"FormularyType":"OHP","DrugName":"CALC CIT+D3 TAB 200-6.25","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"87701042767"},{"Id":420400,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"87701042777"},{"Id":420401,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"87701042789"},{"Id":420402,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"87701042790"},{"Id":420403,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"87701042791"},{"Id":420404,"FormularyType":"OHP","DrugName":"GNP CLEARLAX PAK 3350","DosageForm":"PACK - Packet","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033003020","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM","NDC":"87701042814"},{"Id":420405,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"87701042817"},{"Id":420406,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"87701042818"},{"Id":420407,"FormularyType":"OHP","DrugName":"GNP GAUZE PAD 2X2","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"87701042865"},{"Id":420408,"FormularyType":"OHP","DrugName":"ADHESIVE PAD PAD 3\"X4\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"87701042868"},{"Id":420409,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"87701042902"},{"Id":420410,"FormularyType":"OHP","DrugName":"GNP FISH OIL CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"87701042903"},{"Id":420411,"FormularyType":"OHP","DrugName":"GNP MINERAL OIL","DosageForm":"OIL - Oil","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"87701042917"},{"Id":420412,"FormularyType":"OHP","DrugName":"GNP TRIPLE OIN ANTIBIOT","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"87701042937"},{"Id":420413,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"87701042959"},{"Id":420414,"FormularyType":"OHP","DrugName":"PAIN RELIEF CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"87701042963"},{"Id":420415,"FormularyType":"OHP","DrugName":"GNP ALLERGY CHW 12.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100510","GenericName":"DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG","NDC":"87701042964"},{"Id":420416,"FormularyType":"OHP","DrugName":"GNP DECONGE TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"87701042967"},{"Id":420417,"FormularyType":"OHP","DrugName":"GNP ACETAMIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"87701042971"},{"Id":420418,"FormularyType":"OHP","DrugName":"GNP ANTACID SUS REG ST","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"87701042974"},{"Id":420419,"FormularyType":"OHP","DrugName":"GNP ANTACID SUS COOLMINT","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"87701042975"},{"Id":420420,"FormularyType":"OHP","DrugName":"GNP MILK MAG SUS CHERRY","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"87701042976"},{"Id":420421,"FormularyType":"OHP","DrugName":"GNP MILK MAG SUS MINT","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"87701042977"},{"Id":420422,"FormularyType":"OHP","DrugName":"GNP MILK MAG SUS ORIGINAL","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"87701042978"},{"Id":420423,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"87701042982"},{"Id":420424,"FormularyType":"OHP","DrugName":"GNP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"87701042983"},{"Id":420425,"FormularyType":"OHP","DrugName":"MICONAZORB POW AF 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"87701042990"},{"Id":420426,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"87701042999"},{"Id":420427,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701043000"},{"Id":420428,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"87701043020"},{"Id":420429,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"87701043021"},{"Id":420430,"FormularyType":"OHP","DrugName":"GNP GNTL LAX TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"87701043086"},{"Id":420431,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"87701043108"},{"Id":420432,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"87701043109"},{"Id":420433,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701043130"},{"Id":420434,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"87701043136"},{"Id":420435,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"87701043165"},{"Id":420436,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"87701043190"},{"Id":420437,"FormularyType":"OHP","DrugName":"GNP ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"87701043194"},{"Id":420438,"FormularyType":"OHP","DrugName":"ASPIRIN LOW TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"87701043196"},{"Id":420439,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"87701043204"},{"Id":420440,"FormularyType":"OHP","DrugName":"GNP OMEPRAZO TAB 20MG ODT","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"87701043214"},{"Id":420441,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"87701043215"},{"Id":420442,"FormularyType":"OHP","DrugName":"GNP ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"87701043216"},{"Id":420443,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"87701043227"},{"Id":420444,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"87701043245"},{"Id":420445,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"87701043246"},{"Id":420446,"FormularyType":"OHP","DrugName":"IBUPROFEN CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"87701043252"},{"Id":420447,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"87701043253"},{"Id":420448,"FormularyType":"OHP","DrugName":"GNP GLUCOSE CHW 2GM","DosageForm":"CHEW - Tablet Chewable","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000509","GenericName":"GLUCOSE CHEW TAB 2 GM (CARB EQUIV)","NDC":"87701043259"},{"Id":420449,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"87701043267"},{"Id":420450,"FormularyType":"OHP","DrugName":"GNP PRENATAL TAB FOLIC AC","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"87701043270"},{"Id":420451,"FormularyType":"OHP","DrugName":"GOODSENSE GEL ART PAIN","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"87701043329"},{"Id":420452,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"87701043332"},{"Id":420453,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBCR - Tablet ER","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000440","GenericName":"MELATONIN TAB ER 10 MG","NDC":"87701043334"},{"Id":420454,"FormularyType":"OHP","DrugName":"GNP NICOTINE DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"87701043337"},{"Id":420455,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"87701043340"},{"Id":420456,"FormularyType":"OHP","DrugName":"GNP CHILDREN CHW EXTRA C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"87701043345"},{"Id":420457,"FormularyType":"OHP","DrugName":"GNP CHILDREN CHW EXTRA C","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"87701043346"},{"Id":420458,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"87701043359"},{"Id":420459,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG CHER","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"87701043361"},{"Id":420460,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG FRT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701043362"},{"Id":420461,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"87701043365"},{"Id":420462,"FormularyType":"OHP","DrugName":"GNP OLOPATAD SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"87701043367"},{"Id":420463,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1% OP","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"87701043368"},{"Id":420464,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"87701043371"},{"Id":420465,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 32GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"87701043372"},{"Id":420466,"FormularyType":"OHP","DrugName":"GNP ULTICARE MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"87701043373"},{"Id":420467,"FormularyType":"OHP","DrugName":"GNP ZINC OXI OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"87701043375"},{"Id":420468,"FormularyType":"OHP","DrugName":"ALLERGY RLF LIQ 50/20ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"87701043385"},{"Id":420469,"FormularyType":"OHP","DrugName":"GNP GNTL LAX TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"87701043395"},{"Id":420470,"FormularyType":"OHP","DrugName":"GNP HEADACH TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"87701043396"},{"Id":420471,"FormularyType":"OHP","DrugName":"GNP ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"87701043397"},{"Id":420472,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"87701043401"},{"Id":420473,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"87701043402"},{"Id":420474,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"87701043403"},{"Id":420475,"FormularyType":"OHP","DrugName":"STOOL SOFTNR CAP 250MG","DosageForm":"CAPS - Capsule","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300120","GenericName":"DOCUSATE SODIUM CAP 250 MG","NDC":"87701043404"},{"Id":420476,"FormularyType":"OHP","DrugName":"ADH GAUZE PAD 4\"X4\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97301000004300","GenericName":"*ADHESIVE BANDAGES - PADS***","NDC":"87701043406"},{"Id":420477,"FormularyType":"OHP","DrugName":"SLEEP-AID MS CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"87701043408"},{"Id":420478,"FormularyType":"OHP","DrugName":"GNP PAIN REL TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"87701043409"},{"Id":420479,"FormularyType":"OHP","DrugName":"GNP ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"87701043414"},{"Id":420480,"FormularyType":"OHP","DrugName":"GNP SENNA LX TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"87701043417"},{"Id":420481,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"87701043427"},{"Id":420482,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"87701043428"},{"Id":420483,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"87701043429"},{"Id":420484,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"87701043430"},{"Id":420485,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"87701043431"},{"Id":420486,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"87701043432"},{"Id":420487,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"87701043433"},{"Id":420488,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"87701043434"},{"Id":420489,"FormularyType":"OHP","DrugName":"GNP D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"87701043462"},{"Id":420490,"FormularyType":"OHP","DrugName":"GNP D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"87701043463"},{"Id":420491,"FormularyType":"OHP","DrugName":"GNP D3 CAP 250MCG","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"87701043465"},{"Id":420492,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"87701043473"},{"Id":420493,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"87701043474"},{"Id":420494,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"87701043475"},{"Id":420495,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"87701043476"},{"Id":420496,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701043477"},{"Id":420497,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"87701043478"},{"Id":420498,"FormularyType":"OHP","DrugName":"GNP NICOTINE LOZ MINI 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"87701043479"},{"Id":420499,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"87701043481"},{"Id":420500,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701043482"},{"Id":420501,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701043483"},{"Id":420502,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"87701043484"},{"Id":420503,"FormularyType":"OHP","DrugName":"GNP NICOTINE GUM 4MG ORIG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"87701043485"},{"Id":420504,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"87701043491"},{"Id":420505,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"87701043492"},{"Id":420506,"FormularyType":"OHP","DrugName":"GNP ESOMEPRA CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"87701043493"},{"Id":420507,"FormularyType":"OHP","DrugName":"GNP ESOMEPRA CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"87701043494"},{"Id":420508,"FormularyType":"OHP","DrugName":"GNP ESOMEPRA CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"87701043496"},{"Id":420509,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"87701043497"},{"Id":420510,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"87701043498"},{"Id":420511,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"87701043502"},{"Id":420512,"FormularyType":"OHP","DrugName":"GNP MAG CITR SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"87701043503"},{"Id":420513,"FormularyType":"OHP","DrugName":"8 HR ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"87701043511"},{"Id":420514,"FormularyType":"OHP","DrugName":"GNP MELATONI CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"87701043516"},{"Id":420515,"FormularyType":"OHP","DrugName":"GNP ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"87701043612"},{"Id":420516,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"87701044416"},{"Id":420517,"FormularyType":"OHP","DrugName":"CLOTRIMAZOLE CRE 3 DAY","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104020003710","GenericName":"CLOTRIMAZOLE VAGINAL CREAM 2%","NDC":"87701045401"},{"Id":420518,"FormularyType":"OHP","DrugName":"GNP LANCING MIS DEVICE","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202027006300","GenericName":"*LANCET DEVICES***","NDC":"87701052620"},{"Id":420519,"FormularyType":"OHP","DrugName":"HYDROCORT/ CRE ALOE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"87701054970"},{"Id":420520,"FormularyType":"OHP","DrugName":"HYDROCORT OIN 1%","DosageForm":"OINT - Ointment","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075004210","GenericName":"HYDROCORTISONE OINT 1%","NDC":"87701054973"},{"Id":420521,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500/GM","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"87701055389"},{"Id":420522,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 0.5%","DosageForm":"CREA - Cream","Strength":"0.5","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003715","GenericName":"HYDROCORTISONE CREAM 0.5%","NDC":"87701055397"},{"Id":420523,"FormularyType":"OHP","DrugName":"GNP ELECTROL SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"87701064394"},{"Id":420524,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"87701064932"},{"Id":420525,"FormularyType":"OHP","DrugName":"CHLD ALLERGY LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"87701064954"},{"Id":420526,"FormularyType":"OHP","DrugName":"FIBER-CAPS TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"87701070558"},{"Id":420527,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"87701074723"},{"Id":420528,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701075605"},{"Id":420529,"FormularyType":"OHP","DrugName":"GNP ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"87701079215"},{"Id":420530,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"87701079251"},{"Id":420531,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"87701080042"},{"Id":420532,"FormularyType":"OHP","DrugName":"GNP CHILDREN SUS PAIN&FEV","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"87701082463"},{"Id":420533,"FormularyType":"OHP","DrugName":"GNP CHILDREN SUS PAIN&FEV","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"87701082470"},{"Id":420534,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"87701082676"},{"Id":420535,"FormularyType":"OHP","DrugName":"GNP ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"87701083714"},{"Id":420536,"FormularyType":"OHP","DrugName":"NATURL FIBER POW 28.3%","DosageForm":"POWD - Powder","Strength":"28.3","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102929","GenericName":"PSYLLIUM POWDER 28.3%","NDC":"87701083799"},{"Id":420537,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"87701084242"},{"Id":420538,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"87701089472"},{"Id":420539,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701089897"},{"Id":420540,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701089898"},{"Id":420541,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701090003"},{"Id":420542,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"87701090080"},{"Id":420543,"FormularyType":"OHP","DrugName":"ANTACID CHW 500MG","DosageForm":"CHEW - Tablet Chewable","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000510","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG","NDC":"87701090081"},{"Id":420544,"FormularyType":"OHP","DrugName":"GNP ELECTROL SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"87701090588"},{"Id":420545,"FormularyType":"OHP","DrugName":"GNP ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"87701091009"},{"Id":420546,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"87701091676"},{"Id":420547,"FormularyType":"OHP","DrugName":"MICONAZOLE 3 KIT COMBO PK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050106410","GenericName":"MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT","NDC":"87701092131"},{"Id":420548,"FormularyType":"OHP","DrugName":"LORATADINE SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"87701093206"},{"Id":420549,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN PLUS","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109804434220","GenericName":"NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%","NDC":"87701094584"},{"Id":420550,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"87701095927"},{"Id":420551,"FormularyType":"OHP","DrugName":"PAIN RELIEF TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"87701097945"},{"Id":420552,"FormularyType":"OHP","DrugName":"GNP HYDROCOR CRE 1% PLUS","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"87701098111"},{"Id":420553,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"87701098159"},{"Id":420554,"FormularyType":"OHP","DrugName":"GNP NASAL TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"87701099096"},{"Id":420555,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 10000UNT","DosageForm":"CAPS - Capsule","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000160","GenericName":"CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)","NDC":"88395001421"},{"Id":420556,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"88395001441"},{"Id":420557,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"88395001451"},{"Id":420558,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"88395001452"},{"Id":420559,"FormularyType":"OHP","DrugName":"SUPER DHA CAP GEMS","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"88395001550"},{"Id":420560,"FormularyType":"OHP","DrugName":"SUPER DHA CAP GEMS","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"88395001552"},{"Id":420561,"FormularyType":"OHP","DrugName":"SUPER DHA CAP GEMS","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"88395001553"},{"Id":420562,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 5000UNIT","DosageForm":"CAPS - Capsule","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"88395014110"},{"Id":420563,"FormularyType":"OHP","DrugName":"K-PAX IMMUNE POW BOOSTER","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"88856000055"},{"Id":420564,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146318","GenericName":"INSULIN PEN NEEDLE 29 G X 5 MM (1/5\" OR 3/16\")","NDC":"89134000000"},{"Id":420565,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146322","GenericName":"INSULIN PEN NEEDLE 29 G X 8 MM (1/3\" OR 5/16\")","NDC":"89134000001"},{"Id":420566,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"89134050202"},{"Id":420567,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"89134050302"},{"Id":420568,"FormularyType":"OHP","DrugName":"MAXICOMFORT MIS 27GX1/2","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906310","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2\"","NDC":"89134052602"},{"Id":420569,"FormularyType":"OHP","DrugName":"MAXICOMFORT MIS 27GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"89134052702"},{"Id":420570,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"89134052802"},{"Id":420571,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"89134052902"},{"Id":420572,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"89134061802"},{"Id":420573,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"89134062002"},{"Id":420574,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"89134062202"},{"Id":420575,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146318","GenericName":"INSULIN PEN NEEDLE 29 G X 5 MM (1/5\" OR 3/16\")","NDC":"89134062501"},{"Id":420576,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 29GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146322","GenericName":"INSULIN PEN NEEDLE 29 G X 8 MM (1/3\" OR 5/16\")","NDC":"89134062601"},{"Id":420577,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"89134063002"},{"Id":420578,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"89134063102"},{"Id":420579,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"89134072202"},{"Id":420580,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"89134074002"},{"Id":420581,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"89134074202"},{"Id":420582,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"89134074402"},{"Id":420583,"FormularyType":"OHP","DrugName":"MAXICOMFORT MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"89134310401"},{"Id":420584,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"89134320801"},{"Id":420585,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"89158300600"},{"Id":420586,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"89158300690"},{"Id":420587,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"89158300800"},{"Id":420588,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"89158300890"},{"Id":420589,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"89158301200"},{"Id":420590,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"89158301290"},{"Id":420591,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"89158500400"},{"Id":420592,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"89158500490"},{"Id":420593,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"89158500500"},{"Id":420594,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"89158500590"},{"Id":420595,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"89158500600"},{"Id":420596,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"89158500690"},{"Id":420597,"FormularyType":"OHP","DrugName":"CAREFINE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"89158500800"},{"Id":420598,"FormularyType":"OHP","DrugName":"CAREFINE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"89158500890"},{"Id":420599,"FormularyType":"OHP","DrugName":"NU-IRON 150 CAP","DosageForm":"CAPS - Capsule","Strength":"150","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300050000110","GenericName":"POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT)","NDC":"89411029101"},{"Id":420600,"FormularyType":"OHP","DrugName":"BABY'S BIG POW SUPPORT","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"90011003063"},{"Id":420601,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"90011030003"},{"Id":420602,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"90011030004"},{"Id":420603,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 125MCG","DosageForm":"CAPS - Capsule","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000140","GenericName":"CHOLECALCIFEROL CAP 125 MCG (5000 UNIT)","NDC":"90011030005"},{"Id":420604,"FormularyType":"OHP","DrugName":"TROSPIUM CL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"URINARY ANTISPASMODICS","DrugSubClass":"URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"54100065200320","GenericName":"TROSPIUM CHLORIDE TAB 20 MG","NDC":"90096014160"},{"Id":420605,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"90166005015"},{"Id":420606,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"90166005035"},{"Id":420607,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"90166005055"},{"Id":420608,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"90166005615"},{"Id":420609,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"90166005635"},{"Id":420610,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"90166005655"},{"Id":420611,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 10ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006310","GenericName":"SYRINGE (DISPOSABLE) 10 ML","NDC":"90166010205"},{"Id":420612,"FormularyType":"OHP","DrugName":"GLOBAL PREP PAD PADS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"90166011103"},{"Id":420613,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"90166012122"},{"Id":420614,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 1ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"90166012505"},{"Id":420615,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 1ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006301","GenericName":"SYRINGE (DISPOSABLE) 1 ML","NDC":"90166013505"},{"Id":420616,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"90166013645"},{"Id":420617,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"90166015615"},{"Id":420618,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"90166015635"},{"Id":420619,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"90166015655"},{"Id":420620,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 20ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006320","GenericName":"SYRINGE (DISPOSABLE) 20 ML","NDC":"90166020205"},{"Id":420621,"FormularyType":"OHP","DrugName":"GLOBAL PREP PAD PADS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"90166022203"},{"Id":420622,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"90166023645"},{"Id":420623,"FormularyType":"OHP","DrugName":"PERFECT POIN MIS 25GX1\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051020256320","GenericName":"NEEDLE (DISP) 25 X 1\"","NDC":"90166025105"},{"Id":420624,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"90166025635"},{"Id":420625,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 3ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006303","GenericName":"SYRINGE (DISPOSABLE) 3 ML","NDC":"90166030305"},{"Id":420626,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"90166031645"},{"Id":420627,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"90166033042"},{"Id":420628,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 30ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006330","GenericName":"SYRINGE (DISPOSABLE) 30 ML","NDC":"90166033305"},{"Id":420629,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"90166043152"},{"Id":420630,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"90166043154"},{"Id":420631,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"90166045035"},{"Id":420632,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"90166045635"},{"Id":420633,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 5ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006305","GenericName":"SYRINGE (DISPOSABLE) 5 ML","NDC":"90166056505"},{"Id":420634,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 60ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"90166060601"},{"Id":420635,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"90166063132"},{"Id":420636,"FormularyType":"OHP","DrugName":"EASY GLIDE MIS 60ML SYR","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051010006360","GenericName":"SYRINGE (DISPOSABLE) 60 ML","NDC":"90166066605"},{"Id":420637,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"90166083152"},{"Id":420638,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"90166085015"},{"Id":420639,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"90166085055"},{"Id":420640,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"90166095015"},{"Id":420641,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"90166095035"},{"Id":420642,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"90166095055"},{"Id":420643,"FormularyType":"OHP","DrugName":"LPS CRITICAL LIQ CHERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962000042"},{"Id":420644,"FormularyType":"OHP","DrugName":"LPS SUGAR FR LIQ HONEY VA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962000048"},{"Id":420645,"FormularyType":"OHP","DrugName":"LPS SUGAR FR LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962000049"},{"Id":420646,"FormularyType":"OHP","DrugName":"DPP DIPEPTID LIQ POWER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962000126"},{"Id":420647,"FormularyType":"OHP","DrugName":"FIBER FLOW LIQ NEUTRAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962063732"},{"Id":420648,"FormularyType":"OHP","DrugName":"LPS SUGAR FR LIQ NEUTRAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962069332"},{"Id":420649,"FormularyType":"OHP","DrugName":"LPS SUGAR FR LIQ CHERRY","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962069532"},{"Id":420650,"FormularyType":"OHP","DrugName":"LPS CRITICAL LIQ HONEY VA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"90962069732"},{"Id":420651,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"91237000108"},{"Id":420652,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"91237000109"},{"Id":420653,"FormularyType":"OHP","DrugName":"ALCOHOL PAD","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"91237000128"},{"Id":420654,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"91237000163"},{"Id":420655,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"91237000170"},{"Id":420656,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"91237000171"},{"Id":420657,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"91237000172"},{"Id":420658,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 31GX1/4\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"91237000173"},{"Id":420659,"FormularyType":"OHP","DrugName":"SAPS CARE PAD ALCOHOL","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"91237000176"},{"Id":420660,"FormularyType":"OHP","DrugName":"EASY COMFORT MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"91237000177"},{"Id":420661,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"91237000188"},{"Id":420662,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"91237000189"},{"Id":420663,"FormularyType":"OHP","DrugName":"IMMULIFE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"91717023833"},{"Id":420664,"FormularyType":"OHP","DrugName":"THICK-IT MIS CRANBERR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"92125000256"},{"Id":420665,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"92896000001"},{"Id":420666,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"92896000002"},{"Id":420667,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"92896000003"},{"Id":420668,"FormularyType":"OHP","DrugName":"FIFTY50 MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"92896000020"},{"Id":420669,"FormularyType":"OHP","DrugName":"FIFTY50 MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"92896000021"},{"Id":420670,"FormularyType":"OHP","DrugName":"FIFTY50 PEN MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"92896000023"},{"Id":420671,"FormularyType":"OHP","DrugName":"FIFTY50 PREP PAD PADS","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"92896000081"},{"Id":420672,"FormularyType":"OHP","DrugName":"OVEGA-3 CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"92961002016"},{"Id":420673,"FormularyType":"OHP","DrugName":"OVEGA-3 CAP 500MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000120","GenericName":"*OMEGA-3 FATTY ACIDS CAP 500 MG**","NDC":"92961002021"},{"Id":420674,"FormularyType":"OHP","DrugName":"FREESTYLE MIS UNISTICK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"93815070428"},{"Id":420675,"FormularyType":"OHP","DrugName":"PRECISION LIQ GLUC/KET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"93815080139"},{"Id":420676,"FormularyType":"OHP","DrugName":"MEDISENSE LIQ GLUC-KET","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"93815080312"},{"Id":420677,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"93815098894"},{"Id":420678,"FormularyType":"OHP","DrugName":"MM ACID-PEP TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"93968005147"},{"Id":420679,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"93968011012"},{"Id":420680,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"93968032111"},{"Id":420681,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"93968032513"},{"Id":420682,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"93968033045"},{"Id":420683,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"94030000203"},{"Id":420684,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"94030000205"},{"Id":420685,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"94030000210"},{"Id":420686,"FormularyType":"OHP","DrugName":"PEN NEEDLE MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"94030000211"},{"Id":420687,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"94030000212"},{"Id":420688,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"94030000213"},{"Id":420689,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146340","GenericName":"INSULIN PEN NEEDLE 30 G X 5 MM (1/5\" OR 3/16\")","NDC":"94030000252"},{"Id":420690,"FormularyType":"OHP","DrugName":"ALCOHOL PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"94046000138"},{"Id":420691,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12.7","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146331","GenericName":"INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2\")","NDC":"94046000152"},{"Id":420692,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"94046000162"},{"Id":420693,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"94046000164"},{"Id":420694,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"94046000166"},{"Id":420695,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"94046000168"},{"Id":420696,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"94046000170"},{"Id":420697,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"94046000172"},{"Id":420698,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"94046000173"},{"Id":420699,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"94046000174"},{"Id":420700,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"94046000175"},{"Id":420701,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"94046000176"},{"Id":420702,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"94046000177"},{"Id":420703,"FormularyType":"OHP","DrugName":"EQ ARTHRTS TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"94346000447"},{"Id":420704,"FormularyType":"OHP","DrugName":"ARTHRTS PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"94346002914"},{"Id":420705,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"94346005359"},{"Id":420706,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"94346005746"},{"Id":420707,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"94346006526"},{"Id":420708,"FormularyType":"OHP","DrugName":"SV VIT D3 CAP 25MCG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"94346006533"},{"Id":420709,"FormularyType":"OHP","DrugName":"SV VIT D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"94346006534"},{"Id":420710,"FormularyType":"OHP","DrugName":"MELATONIN TAB 1MG","DosageForm":"TABS - Tablet","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000320","GenericName":"MELATONIN TAB 1 MG","NDC":"94604010075"},{"Id":420711,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"94604010078"},{"Id":420712,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"94604010079"},{"Id":420713,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"94604010192"},{"Id":420714,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"94604010195"},{"Id":420715,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"94604010198"},{"Id":420716,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 5000IU","DosageForm":"TABS - Tablet","Strength":"5000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"94604010199"},{"Id":420717,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"94604010340"},{"Id":420718,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000310","GenericName":"PYRIDOXINE HCL TAB 50 MG","NDC":"94604010400"},{"Id":420719,"FormularyType":"OHP","DrugName":"VITAMIN B-6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"94604010410"},{"Id":420720,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 250MCG","DosageForm":"TABS - Tablet","Strength":"250","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000320","GenericName":"CYANOCOBALAMIN TAB 250 MCG","NDC":"94604010430"},{"Id":420721,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"94604010440"},{"Id":420722,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"94604010450"},{"Id":420723,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"94604010473"},{"Id":420724,"FormularyType":"OHP","DrugName":"OMEGA-3 CF CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"94604021289"},{"Id":420725,"FormularyType":"OHP","DrugName":"CALCITRATE TAB PLUS D","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"94604049455"},{"Id":420726,"FormularyType":"OHP","DrugName":"NAT-RUL CAL TAB /D 500MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640333","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-3.125 MCG (125 UNIT)","NDC":"94604049456"},{"Id":420727,"FormularyType":"OHP","DrugName":"FERROTABS TAB","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"94604049521"},{"Id":420728,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"94604049526"},{"Id":420729,"FormularyType":"OHP","DrugName":"CALCIUM + D TAB 600MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640350","GenericName":"CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-5 MCG(200 UNIT)","NDC":"94604049536"},{"Id":420730,"FormularyType":"OHP","DrugName":"OMEGA-3 CAP 1000MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000190","GenericName":"*OMEGA-3 FATTY ACIDS CAP 1000 MG**","NDC":"94604062947"},{"Id":420731,"FormularyType":"OHP","DrugName":"NAT-RUL IRON TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"94604070202"},{"Id":420732,"FormularyType":"OHP","DrugName":"PROSOURCE POW","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"94688001162"},{"Id":420733,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688001454"},{"Id":420734,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688001476"},{"Id":420735,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688001486"},{"Id":420736,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688001525"},{"Id":420737,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688001535"},{"Id":420738,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688001545"},{"Id":420739,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688001651"},{"Id":420740,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688001661"},{"Id":420741,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688001671"},{"Id":420742,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688001854"},{"Id":420743,"FormularyType":"OHP","DrugName":"XTRACAL LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688006866"},{"Id":420744,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011432"},{"Id":420745,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ TF","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011444"},{"Id":420746,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011454"},{"Id":420747,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688011476"},{"Id":420748,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688011486"},{"Id":420749,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688011525"},{"Id":420750,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688011535"},{"Id":420751,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ NO CARB","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"94688011545"},{"Id":420752,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ ZAC","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011555"},{"Id":420753,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011651"},{"Id":420754,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011661"},{"Id":420755,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011671"},{"Id":420756,"FormularyType":"OHP","DrugName":"GELATEIN MCT LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011715"},{"Id":420757,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ PLUS","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688011854"},{"Id":420758,"FormularyType":"OHP","DrugName":"PROSOURCE LIQ XTRACAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688016866"},{"Id":420759,"FormularyType":"OHP","DrugName":"EXPEDITE LIQ PCH/MAN","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"94688018800"},{"Id":420760,"FormularyType":"OHP","DrugName":"KERALYT GEL 3%","DosageForm":"GEL - Gel","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004080","GenericName":"SALICYLIC ACID GEL 3%","NDC":"94731003801"},{"Id":420761,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"94743000100"},{"Id":420762,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"94743000114"},{"Id":420763,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"94743000170"},{"Id":420764,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"94743000171"},{"Id":420765,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"94743000172"},{"Id":420766,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX1/2\"","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"94743000173"},{"Id":420767,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"94743000174"},{"Id":420768,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 30GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146344","GenericName":"INSULIN PEN NEEDLE 30 G X 8 MM (1/3\" OR 5/16\")","NDC":"94743000175"},{"Id":420769,"FormularyType":"OHP","DrugName":"CAREFINE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"94743000176"},{"Id":420770,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"94743000177"},{"Id":420771,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"94743000178"},{"Id":420772,"FormularyType":"OHP","DrugName":"CAREFINE MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"94743000179"},{"Id":420773,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"94743000180"},{"Id":420774,"FormularyType":"OHP","DrugName":"CAREFINE MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"94743000181"},{"Id":420775,"FormularyType":"OHP","DrugName":"THERAGAUZE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"94922068294"},{"Id":420776,"FormularyType":"OHP","DrugName":"ESPRESSO POW PROTEIN","DosageForm":"POWD - Powder","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000002900","GenericName":"*NUTRITIONAL SUPPLEMENT POWDER**","NDC":"94922077386"},{"Id":420777,"FormularyType":"OHP","DrugName":"OTC ANTIGENT KIT 2-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"95893053317"},{"Id":420778,"FormularyType":"OHP","DrugName":"OTC ANTIGENT KIT 1-PACK","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024356400","GenericName":"COVID-19 AT HOME ANTIGEN TEST KIT","NDC":"95893077490"},{"Id":420779,"FormularyType":"OHP","DrugName":"SIMPLICITY KIT COVID-19","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94101024306400","GenericName":"COVID-19 HOME COLLECTION TEST KIT","NDC":"95893095898"},{"Id":420780,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 800MCG","DosageForm":"TABS - Tablet","Strength":"800","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000310","GenericName":"FOLIC ACID TAB 800 MCG","NDC":"96121000239"},{"Id":420781,"FormularyType":"OHP","DrugName":"VITAMIN D TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"96121000261"},{"Id":420782,"FormularyType":"OHP","DrugName":"VITAMIN D CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000105","GenericName":"CHOLECALCIFEROL CAP 10 MCG (400 UNIT)","NDC":"96121000262"},{"Id":420783,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 400UNIT","DosageForm":"CAPS - Capsule","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000135","GenericName":"VITAMIN E CAP 400 UNIT","NDC":"96121000265"},{"Id":420784,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"96295010245"},{"Id":420785,"FormularyType":"OHP","DrugName":"STERILE PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"96295010286"},{"Id":420786,"FormularyType":"OHP","DrugName":"D3 CAP 1000UNIT","DosageForm":"CAPS - Capsule","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000110","GenericName":"CHOLECALCIFEROL CAP 25 MCG (1000 UNIT)","NDC":"96295012323"},{"Id":420787,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 10000UNT","DosageForm":"TABS - Tablet","Strength":"10000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000360","GenericName":"CHOLECALCIFEROL TAB 250 MCG (10000 UNIT)","NDC":"96295012564"},{"Id":420788,"FormularyType":"OHP","DrugName":"ENEMA READY- ENE TO-USE","DosageForm":"ENEM - Enema","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46109902105100","GenericName":"*SODIUM PHOSPHATES - ENEMA***","NDC":"96295012752"},{"Id":420789,"FormularyType":"OHP","DrugName":"ALCOHOL SWAB PAD 70%","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"96295012768"},{"Id":420790,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"96295012792"},{"Id":420791,"FormularyType":"OHP","DrugName":"CALC CITR+D3 TAB 200-250","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660318","GenericName":"CALCIUM CIT-VIT D TAB 200 MG-6.25 MCG(250 UNIT) (ELEM CA)","NDC":"96295012824"},{"Id":420792,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"96295012827"},{"Id":420793,"FormularyType":"OHP","DrugName":"IRON TAB 27MG","DosageForm":"TABS - Tablet","Strength":"240","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300020000308","GenericName":"FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE)","NDC":"96295012829"},{"Id":420794,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"96295012831"},{"Id":420795,"FormularyType":"OHP","DrugName":"PRENATAL TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PRENATAL VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"50","AgeMaxUnit":"Y","GenericProductIdentifier":"78512015000328","GenericName":"*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG***","NDC":"96295012833"},{"Id":420796,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 400UNIT","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000320","GenericName":"CHOLECALCIFEROL TAB 10 MCG (400 UNIT)","NDC":"96295012845"},{"Id":420797,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 2000UNIT","DosageForm":"TABS - Tablet","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000340","GenericName":"CHOLECALCIFEROL TAB 50 MCG (2000 UNIT)","NDC":"96295012847"},{"Id":420798,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 1000UNIT","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000330","GenericName":"CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)","NDC":"96295012848"},{"Id":420799,"FormularyType":"OHP","DrugName":"MULTIVITAMIN CHW CHILDREN","DosageForm":"CHEW - Tablet Chewable","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"18","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000000500","GenericName":"*PEDIATRIC MULTIPLE VITAMIN CHEW TAB**","NDC":"96295012864"},{"Id":420800,"FormularyType":"OHP","DrugName":"ALLERGY CHLD SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"96295012925"},{"Id":420801,"FormularyType":"OHP","DrugName":"HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"96295012960"},{"Id":420802,"FormularyType":"OHP","DrugName":"TRI-BUFF ASA TAB 325MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64109902040320","GenericName":"ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG","NDC":"96295012961"},{"Id":420803,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"96295012964"},{"Id":420804,"FormularyType":"OHP","DrugName":"ALLERGY TAB 4MG","DosageForm":"TABS - Tablet","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ALKYLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41100020150310","GenericName":"CHLORPHENIRAMINE MALEATE TAB 4 MG","NDC":"96295012989"},{"Id":420805,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"96295013014"},{"Id":420806,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013021"},{"Id":420807,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"96295013024"},{"Id":420808,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013030"},{"Id":420809,"FormularyType":"OHP","DrugName":"NASAL ALLRGY SPR 55MCG/AC","DosageForm":"AERO - Aerosol","Strength":"55","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"NASAL STEROIDS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42200060103210","GenericName":"TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","NDC":"96295013053"},{"Id":420810,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"96295013071"},{"Id":420811,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"96295013073"},{"Id":420812,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"96295013074"},{"Id":420813,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"96295013075"},{"Id":420814,"FormularyType":"OHP","DrugName":"ALL DAY ALLG SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"96295013077"},{"Id":420815,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"96295013089"},{"Id":420816,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100305","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG","NDC":"96295013109"},{"Id":420817,"FormularyType":"OHP","DrugName":"IBUPROFEN JR CHW 100MG","DosageForm":"CHEW - Tablet Chewable","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000520","GenericName":"IBUPROFEN CHEW TAB 100 MG","NDC":"96295013114"},{"Id":420818,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"96295013132"},{"Id":420819,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"96295013133"},{"Id":420820,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"96295013147"},{"Id":420821,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"96295013159"},{"Id":420822,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"96295013163"},{"Id":420823,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"96295013164"},{"Id":420824,"FormularyType":"OHP","DrugName":"IBUPROFEN SUS 100/5ML","DosageForm":"SUSP - Suspension","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001820","GenericName":"IBUPROFEN SUSP 100 MG/5ML","NDC":"96295013165"},{"Id":420825,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013196"},{"Id":420826,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013203"},{"Id":420827,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013204"},{"Id":420828,"FormularyType":"OHP","DrugName":"IBUPROFEN DRO 50/1.25","DosageForm":"SUSP - Suspension","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020001810","GenericName":"IBUPROFEN SUSP 40 MG/ML","NDC":"96295013205"},{"Id":420829,"FormularyType":"OHP","DrugName":"ELECTROLYTE SOL UNFLAVOR","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"96295013218"},{"Id":420830,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013220"},{"Id":420831,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013221"},{"Id":420832,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013223"},{"Id":420833,"FormularyType":"OHP","DrugName":"ACETAMIN JR CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"96295013224"},{"Id":420834,"FormularyType":"OHP","DrugName":"ACETAMINOPHE CHW 160MG","DosageForm":"CHEW - Tablet Chewable","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000515","GenericName":"ACETAMINOPHEN CHEW TAB 160 MG","NDC":"96295013225"},{"Id":420835,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013234"},{"Id":420836,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL FRUIT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"96295013262"},{"Id":420837,"FormularyType":"OHP","DrugName":"PED ELCTRLYT SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"ELECTROLYTE MIXTURES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79991000002000","GenericName":"*ORAL ELECTROLYTE SOLUTION***","NDC":"96295013263"},{"Id":420838,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"96295013276"},{"Id":420839,"FormularyType":"OHP","DrugName":"ZINC OXIDE OIN 20%","DosageForm":"OINT - Ointment","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971020004210","GenericName":"ZINC OXIDE OINT 20%","NDC":"96295013322"},{"Id":420840,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90150087103710","GenericName":"TERBINAFINE HCL CREAM 1%","NDC":"96295013323"},{"Id":420841,"FormularyType":"OHP","DrugName":"MICONAZOLE CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050103705","GenericName":"MICONAZOLE NITRATE CREAM 2%","NDC":"96295013332"},{"Id":420842,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"96295013375"},{"Id":420843,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"96295013376"},{"Id":420844,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MGFRUIT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"96295013377"},{"Id":420845,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG MINT","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"96295013378"},{"Id":420846,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"96295013379"},{"Id":420847,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MGFRUIT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"96295013380"},{"Id":420848,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"96295013381"},{"Id":420849,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 4MG MINT","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"96295013382"},{"Id":420850,"FormularyType":"OHP","DrugName":"NICOTINE POL GUM 2MG ORIG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"96295013383"},{"Id":420851,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295013407"},{"Id":420852,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295013408"},{"Id":420853,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295013409"},{"Id":420854,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295013410"},{"Id":420855,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"96295013457"},{"Id":420856,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013466"},{"Id":420857,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013467"},{"Id":420858,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013468"},{"Id":420859,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013470"},{"Id":420860,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"96295013478"},{"Id":420861,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"96295013479"},{"Id":420862,"FormularyType":"OHP","DrugName":"ALL DAY ALLG TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"96295013481"},{"Id":420863,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"96295013483"},{"Id":420864,"FormularyType":"OHP","DrugName":"OMEPRAZOLE TAB ODT 20MG","DosageForm":"TBDD - Tab DR Disint","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"4927006000H320","GenericName":"OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG","NDC":"96295013484"},{"Id":420865,"FormularyType":"OHP","DrugName":"MOTION SICK TAB 50MG","DosageForm":"TABS - Tablet","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200030000310","GenericName":"DIMENHYDRINATE TAB 50 MG","NDC":"96295013518"},{"Id":420866,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013526"},{"Id":420867,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013527"},{"Id":420868,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"96295013543"},{"Id":420869,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"96295013544"},{"Id":420870,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"96295013545"},{"Id":420871,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"96295013555"},{"Id":420872,"FormularyType":"OHP","DrugName":"ASPIRIN CHW 81MG","DosageForm":"CHEW - Tablet Chewable","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000510","GenericName":"ASPIRIN CHEW TAB 81 MG","NDC":"96295013556"},{"Id":420873,"FormularyType":"OHP","DrugName":"FOLIC ACID TAB 400MCG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"FOLIC ACID/FOLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82200010000305","GenericName":"FOLIC ACID TAB 400 MCG","NDC":"96295013565"},{"Id":420874,"FormularyType":"OHP","DrugName":"IRON SLOW TAB 45MG","DosageForm":"TBCR - Tablet ER","Strength":"45","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000453","GenericName":"FERROUS SULFATE TAB ER 45 MG (ELEMENTAL FE)","NDC":"96295013568"},{"Id":420875,"FormularyType":"OHP","DrugName":"CALCIUM + D3 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902660330","GenericName":"CALCIUM CIT-VITAMIN D TAB 315 MG-5 MCG(200 UNIT) (ELEM CA)","NDC":"96295013569"},{"Id":420876,"FormularyType":"OHP","DrugName":"CALCIUM/D3 TAB","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79109902640340","GenericName":"CALCIUM CARB-CHOLECALCIFEROL TAB 500 MG-10 MCG (400 UNIT)","NDC":"96295013570"},{"Id":420877,"FormularyType":"OHP","DrugName":"IRON TAB 65MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010000332","GenericName":"FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)","NDC":"96295013571"},{"Id":420878,"FormularyType":"OHP","DrugName":"MELATONIN TAB 5MG","DosageForm":"TABS - Tablet","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000350","GenericName":"MELATONIN TAB 5 MG","NDC":"96295013572"},{"Id":420879,"FormularyType":"OHP","DrugName":"MAGNESIUM OX TAB 400MG","DosageForm":"TABS - Tablet","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"MAGNESIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79400010360317","GenericName":"MAGNESIUM OXIDE TAB 400 MG (240 MG ELEMENTAL MG)","NDC":"96295013573"},{"Id":420880,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 1000 TR","DosageForm":"TBCR - Tablet ER","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000430","GenericName":"CYANOCOBALAMIN TAB ER 1000 MCG","NDC":"96295013579"},{"Id":420881,"FormularyType":"OHP","DrugName":"VITAMIN B-12 TAB 1000MCG","DosageForm":"TABS - Tablet","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000330","GenericName":"CYANOCOBALAMIN TAB 1000 MCG","NDC":"96295013587"},{"Id":420882,"FormularyType":"OHP","DrugName":"CALCIUM TAB 600MG","DosageForm":"TABS - Tablet","Strength":"600","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"CALCIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79100007000350","GenericName":"CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA)","NDC":"96295013589"},{"Id":420883,"FormularyType":"OHP","DrugName":"MELATONIN TAB 12MG","DosageForm":"TABS - Tablet","Strength":"12","BrandVsGeneric":"N","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000365","GenericName":"MELATONIN TAB 12 MG","NDC":"96295013590"},{"Id":420884,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 2000MCG","DosageForm":"TBCR - Tablet ER","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000440","GenericName":"CYANOCOBALAMIN TAB ER 2000 MCG","NDC":"96295013599"},{"Id":420885,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295013602"},{"Id":420886,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295013603"},{"Id":420887,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 1GM","DosageForm":"SUPP - Suppository","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005206","GenericName":"GLYCERIN SUPPOS 1 GM","NDC":"96295013613"},{"Id":420888,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"96295013624"},{"Id":420889,"FormularyType":"OHP","DrugName":"LAXATIVE REG TAB 15MG","DosageForm":"TABS - Tablet","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200315","GenericName":"SENNOSIDES TAB 15 MG","NDC":"96295013625"},{"Id":420890,"FormularyType":"OHP","DrugName":"MINERAL OIL","DosageForm":"OIL - Oil","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LUBRICANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46400010001700","GenericName":"MINERAL OIL","NDC":"96295013630"},{"Id":420891,"FormularyType":"OHP","DrugName":"DAILY FIBER POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"96295013640"},{"Id":420892,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295013642"},{"Id":420893,"FormularyType":"OHP","DrugName":"ALLERGY RELF LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"96295013669"},{"Id":420894,"FormularyType":"OHP","DrugName":"ALLERGY RELF SOL 5MG/5ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030002020","GenericName":"LORATADINE ORAL SOLN 5 MG/5ML","NDC":"96295013671"},{"Id":420895,"FormularyType":"OHP","DrugName":"CHOC LAXATIV CHW 15MG","DosageForm":"CHEW - Tablet Chewable","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200515","GenericName":"SENNOSIDES CHEW TAB 15 MG","NDC":"96295013672"},{"Id":420896,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"96295013673"},{"Id":420897,"FormularyType":"OHP","DrugName":"VITAMIN B12 TAB 500MCG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"COBALAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82100010000325","GenericName":"CYANOCOBALAMIN TAB 500 MCG","NDC":"96295013675"},{"Id":420898,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"96295013687"},{"Id":420899,"FormularyType":"OHP","DrugName":"MELATONIN TAB 3MG","DosageForm":"TABS - Tablet","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000340","GenericName":"MELATONIN TAB 3 MG","NDC":"96295013723"},{"Id":420900,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295013746"},{"Id":420901,"FormularyType":"OHP","DrugName":"MICONAZOLE 7 CRE 2%","DosageForm":"CREA - Cream","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"VAGINAL AND RELATED PRODUCTS","DrugSubClass":"VAGINAL ANTI-INFECTIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"55104050103710","GenericName":"MICONAZOLE NITRATE VAGINAL CREAM 2%","NDC":"96295013771"},{"Id":420902,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG EC","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"96295013772"},{"Id":420903,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"96295013785"},{"Id":420904,"FormularyType":"OHP","DrugName":"NASAL DECONG TAB 30MG","DosageForm":"TABS - Tablet","Strength":"30","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020100305","GenericName":"PSEUDOEPHEDRINE HCL TAB 30 MG","NDC":"96295013786"},{"Id":420905,"FormularyType":"OHP","DrugName":"ALCOHOL WIPE MIS 70%","DosageForm":"MISC - Miscellaneous","Strength":"70","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"MISC. TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90971501406320","GenericName":"ISOPROPYL ALCOHOL WIPES 70%","NDC":"96295013789"},{"Id":420906,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"96295013793"},{"Id":420907,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"96295013798"},{"Id":420908,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"96295013799"},{"Id":420909,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96295013807"},{"Id":420910,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TBEC - Tablet DR","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000605","GenericName":"ASPIRIN TAB DELAYED RELEASE 325 MG","NDC":"96295013808"},{"Id":420911,"FormularyType":"OHP","DrugName":"DAILY FIBER POW 43%","DosageForm":"POWD - Powder","Strength":"43","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300030102943","GenericName":"PSYLLIUM POWDER 43%","NDC":"96295013818"},{"Id":420912,"FormularyType":"OHP","DrugName":"MELATONIN CAP 10MG","DosageForm":"CAPS - Capsule","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000160","GenericName":"MELATONIN CAP 10 MG","NDC":"96295013820"},{"Id":420913,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"96295013826"},{"Id":420914,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"96295013827"},{"Id":420915,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"96295013828"},{"Id":420916,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 7MG/24HR","DosageForm":"PT24 - Patch 24 HR","Strength":"7","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008520","GenericName":"NICOTINE TD PATCH 24HR 7 MG/24HR","NDC":"96295013829"},{"Id":420917,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 14MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"14","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008530","GenericName":"NICOTINE TD PATCH 24HR 14 MG/24HR","NDC":"96295013830"},{"Id":420918,"FormularyType":"OHP","DrugName":"NICOTINE TD DIS 21MG/24H","DosageForm":"PT24 - Patch 24 HR","Strength":"21","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100005008540","GenericName":"NICOTINE TD PATCH 24HR 21 MG/24HR","NDC":"96295013831"},{"Id":420919,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"96295013850"},{"Id":420920,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"96295013851"},{"Id":420921,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"96295013852"},{"Id":420922,"FormularyType":"OHP","DrugName":"VITAMIN E CAP 450MG","DosageForm":"CAPS - Capsule","Strength":"450","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77203050000143","GenericName":"VITAMIN E CAP 450 MG (1000 UNIT)","NDC":"96295013857"},{"Id":420923,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"96295013873"},{"Id":420924,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX3/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"96295013874"},{"Id":420925,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"96295013875"},{"Id":420926,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX5/16","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"96295013876"},{"Id":420927,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"96295013877"},{"Id":420928,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX5/32","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"96295013878"},{"Id":420929,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"96295013880"},{"Id":420930,"FormularyType":"OHP","DrugName":"STOOL SOFTNR TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"96295013881"},{"Id":420931,"FormularyType":"OHP","DrugName":"SENNA PLUS TAB 8.6-50MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVE COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46991002770320","GenericName":"SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG","NDC":"96295013882"},{"Id":420932,"FormularyType":"OHP","DrugName":"VITAMIN B6 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77105010000315","GenericName":"PYRIDOXINE HCL TAB 100 MG","NDC":"96295013883"},{"Id":420933,"FormularyType":"OHP","DrugName":"SUPER B COMP TAB + VIT C","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"MULTIVITAMINS","DrugSubClass":"B-COMPLEX W/ C","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"78120000000300","GenericName":"*B-COMPLEX W/ C TAB**","NDC":"96295013884"},{"Id":420934,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"96295013887"},{"Id":420935,"FormularyType":"OHP","DrugName":"EYE ITCH REL DRO 0.035%OP","DosageForm":"SOLN - Solution","Strength":"0.035","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802040102011","GenericName":"KETOTIFEN FUMARATE OPHTH SOLN 0.035%","NDC":"96295013888"},{"Id":420936,"FormularyType":"OHP","DrugName":"VITAMIN B1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010200320","GenericName":"THIAMINE MONONITRATE TAB 100 MG","NDC":"96295013892"},{"Id":420937,"FormularyType":"OHP","DrugName":"THERAPEUTIC SHA 3%","DosageForm":"SHAM - Shampoo","Strength":"3","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"KERATOLYTIC/ANTIMITOTIC/VESICANT AGENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90750030004515","GenericName":"SALICYLIC ACID SHAMPOO 3%","NDC":"96295013896"},{"Id":420938,"FormularyType":"OHP","DrugName":"GENTLE LAXAT TAB 5MG EC","DosageForm":"TBEC - Tablet DR","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010000610","GenericName":"BISACODYL TAB DELAYED RELEASE 5 MG","NDC":"96295013903"},{"Id":420939,"FormularyType":"OHP","DrugName":"ATHLETE FOOT CRE 1%","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154020003705","GenericName":"CLOTRIMAZOLE CREAM 1%","NDC":"96295013908"},{"Id":420940,"FormularyType":"OHP","DrugName":"BACITR ZINC OIN 500UNIT","DosageForm":"OINT - Ointment","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90100010104210","GenericName":"BACITRACIN ZINC OINT 500 UNIT/GM","NDC":"96295013909"},{"Id":420941,"FormularyType":"OHP","DrugName":"CAPSAICIN CRE 0.1%","DosageForm":"CREA - Cream","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"LOCAL ANESTHETICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90850025003735","GenericName":"CAPSAICIN CREAM 0.1%","NDC":"96295013915"},{"Id":420942,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"96295013916"},{"Id":420943,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000360","GenericName":"MELATONIN TAB 10 MG","NDC":"96295013917"},{"Id":420944,"FormularyType":"OHP","DrugName":"POTASSIUM TAB 99MG","DosageForm":"TABS - Tablet","Strength":"595","BrandVsGeneric":"Y","DrugCategory":"MINERALS & ELECTROLYTES","DrugSubClass":"POTASSIUM","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"79700050000370","GenericName":"POTASSIUM GLUCONATE TAB 595 MG (99 MG EQUIV K)","NDC":"96295013923"},{"Id":420945,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"96295013933"},{"Id":420946,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295013958"},{"Id":420947,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"96295013962"},{"Id":420948,"FormularyType":"OHP","DrugName":"ACID REDUCER TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000310","GenericName":"FAMOTIDINE TAB 10 MG","NDC":"96295013963"},{"Id":420949,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"96295013967"},{"Id":420950,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"96295013974"},{"Id":420951,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"96295013975"},{"Id":420952,"FormularyType":"OHP","DrugName":"ARTHR PAIN GEL 1%","DosageForm":"GEL - Gel","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTI-INFLAMMATORY AGENTS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90210030304020","GenericName":"DICLOFENAC SODIUM GEL 1% (1.16% DIETHYLAMINE EQUIV)","NDC":"96295013976"},{"Id":420953,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"96295013978"},{"Id":420954,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINI","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"96295013979"},{"Id":420955,"FormularyType":"OHP","DrugName":"NICOTINE LOZ 4MG MINT","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"96295013980"},{"Id":420956,"FormularyType":"OHP","DrugName":"NICOTINE POL LOZ 2MG MINT","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"96295013981"},{"Id":420957,"FormularyType":"OHP","DrugName":"SLEEP-AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"96295013989"},{"Id":420958,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH REL","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"96295014006"},{"Id":420959,"FormularyType":"OHP","DrugName":"EYE ALLERGY SOL ITCH/RED","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"96295014007"},{"Id":420960,"FormularyType":"OHP","DrugName":"ANTACID SUS MINT","DosageForm":"SUSP - Suspension","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACID COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48991003101810","GenericName":"ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML","NDC":"96295014016"},{"Id":420961,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"96295014018"},{"Id":420962,"FormularyType":"OHP","DrugName":"MILK OF MAGN SUS 1200/15","DosageForm":"SUSP - Suspension","Strength":"1200","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100010101820","GenericName":"MAGNESIUM HYDROXIDE SUSP 400 MG/5ML","NDC":"96295014020"},{"Id":420963,"FormularyType":"OHP","DrugName":"HEADACHE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"96295014026"},{"Id":420964,"FormularyType":"OHP","DrugName":"FIBR LAX+CAL TAB 625MG","DosageForm":"TABS - Tablet","Strength":"625","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"BULK LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46300020100310","GenericName":"CALCIUM POLYCARBOPHIL TAB 625 MG","NDC":"96295014027"},{"Id":420965,"FormularyType":"OHP","DrugName":"VITAMIN D3 TAB 125MCG","DosageForm":"TABS - Tablet","Strength":"125","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000350","GenericName":"CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)","NDC":"96295014036"},{"Id":420966,"FormularyType":"OHP","DrugName":"LAXATIVE MAX TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200325","GenericName":"SENNOSIDES TAB 25 MG","NDC":"96295014047"},{"Id":420967,"FormularyType":"OHP","DrugName":"VITAMI A-C-D DRO INFANT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002019","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 250 MCG-10 MCG-50MG/ML***","NDC":"96295014063"},{"Id":420968,"FormularyType":"OHP","DrugName":"VITAMIN D DRO 10MCG","DosageForm":"LIQD - Liquid","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"96295014064"},{"Id":420969,"FormularyType":"OHP","DrugName":"IRON INF-TOD DRO 15MG","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"96295014065"},{"Id":420970,"FormularyType":"OHP","DrugName":"MULTIVITAMIN DRO INFANT","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"96295014066"},{"Id":420971,"FormularyType":"OHP","DrugName":"MULTI/IRON/ DRO 11MG/ML","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002012","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML**","NDC":"96295014067"},{"Id":420972,"FormularyType":"OHP","DrugName":"ACETAMINOPHN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000310","GenericName":"ACETAMINOPHEN TAB 325 MG","NDC":"96295014079"},{"Id":420973,"FormularyType":"OHP","DrugName":"GLYCERIN SUP 2GM","DosageForm":"SUPP - Suppository","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600010005215","GenericName":"GLYCERIN SUPPOS 2 GM","NDC":"96295014080"},{"Id":420974,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"96295014081"},{"Id":420975,"FormularyType":"OHP","DrugName":"GENTLE LAXAT SUP 10MG","DosageForm":"SUPP - Suppository","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200010005205","GenericName":"BISACODYL SUPPOS 10 MG","NDC":"96295014082"},{"Id":420976,"FormularyType":"OHP","DrugName":"ASPIRIN TAB 325MG","DosageForm":"TABS - Tablet","Strength":"325","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000315","GenericName":"ASPIRIN TAB 325 MG","NDC":"96295014083"},{"Id":420977,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"96295014092"},{"Id":420978,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"96295014093"},{"Id":420979,"FormularyType":"OHP","DrugName":"IBUPROFEN CAP 200MG","DosageForm":"CAPS - Capsule","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000105","GenericName":"IBUPROFEN CAP 200 MG","NDC":"96295014094"},{"Id":420980,"FormularyType":"OHP","DrugName":"TRIPLE ANTIB OIN","DosageForm":"OINT - Ointment","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIBIOTICS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90109803104200","GenericName":"*NEOMYCIN-BACITRACIN-POLYMYXIN OINT***","NDC":"96295014096"},{"Id":420981,"FormularyType":"OHP","DrugName":"MOTION SICKN TAB 25 MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIEMETICS","DrugSubClass":"ANTIEMETICS - ANTICHOLINERGIC","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"50200050000310","GenericName":"MECLIZINE HCL TAB 25 MG","NDC":"96295014099"},{"Id":420982,"FormularyType":"OHP","DrugName":"GAUZE PAD PAD 2\"X2\"","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"BANDAGES-DRESSINGS-TAPE","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97303000004309","GenericName":"*GAUZE PADS & DRESSINGS - PADS 2\" X 2\"***","NDC":"96295014128"},{"Id":420983,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295014135"},{"Id":420984,"FormularyType":"OHP","DrugName":"STOMACH RELE TAB 262MG","DosageForm":"TABS - Tablet","Strength":"262","BrandVsGeneric":"Y","DrugCategory":"ANTIDIARRHEAL/PROBIOTIC AGENTS","DrugSubClass":"ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"47300010000307","GenericName":"BISMUTH SUBSALICYLATE TAB 262 MG","NDC":"96295014137"},{"Id":420985,"FormularyType":"OHP","DrugName":"MELATONIN TAB 10MG","DosageForm":"TBDP - Tablet Disintegrating","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536007260","GenericName":"MELATONIN TABLET DISINTEGRATING 10 MG","NDC":"96295014140"},{"Id":420986,"FormularyType":"OHP","DrugName":"MELATONIN SUB 5MG","DosageForm":"SUBL - Tab Sublingual","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000740","GenericName":"MELATONIN SL TAB 5 MG","NDC":"96295014141"},{"Id":420987,"FormularyType":"OHP","DrugName":"ALLERGY RELF CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"96295014144"},{"Id":420988,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100105","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 25 MG","NDC":"96295014145"},{"Id":420989,"FormularyType":"OHP","DrugName":"12HR ALLERGY TAB 60MG","DosageForm":"TABS - Tablet","Strength":"60","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100320","GenericName":"FEXOFENADINE HCL TAB 60 MG","NDC":"96295014147"},{"Id":420990,"FormularyType":"OHP","DrugName":"MELATONIN LIQ 5MG/20ML","DosageForm":"LIQD - Liquid","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000920","GenericName":"MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML)","NDC":"96295014149"},{"Id":420991,"FormularyType":"OHP","DrugName":"VITAMIN D3 CHW 25MCG","DosageForm":"CHEW - Tablet Chewable","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000550","GenericName":"CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)","NDC":"96295014158"},{"Id":420992,"FormularyType":"OHP","DrugName":"MELATONIN CHW 2.5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"2.5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000535","GenericName":"MELATONIN CHEW TAB 2.5 MG","NDC":"96295014159"},{"Id":420993,"FormularyType":"OHP","DrugName":"MELATONIN CHW 5MG","DosageForm":"CHEW - Tablet Chewable","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ALTERNATIVE MEDICINES","DrugSubClass":"ALTERNATIVE MEDICINE - M'S","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"95391536000545","GenericName":"MELATONIN CHEW TAB 5 MG","NDC":"96295014160"},{"Id":420994,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295014165"},{"Id":420995,"FormularyType":"OHP","DrugName":"SMOOTH ANTA CHW FRUIT","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295014166"},{"Id":420996,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 2000UNIT","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"96295014175"},{"Id":420997,"FormularyType":"OHP","DrugName":"VITAMIN D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"96295014177"},{"Id":420998,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"96295014180"},{"Id":420999,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"96295014181"},{"Id":421000,"FormularyType":"OHP","DrugName":"SENNA TAB 8.6MG","DosageForm":"TABS - Tablet","Strength":"8.6","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"STIMULANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46200060200303","GenericName":"SENNOSIDES TAB 8.6 MG","NDC":"96295014182"},{"Id":421001,"FormularyType":"OHP","DrugName":"ALLERGY CAP 25MG","DosageForm":"CAPS - Capsule","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100105","GenericName":"DIPHENHYDRAMINE HCL CAP 25 MG","NDC":"96295014183"},{"Id":421002,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295014186"},{"Id":421003,"FormularyType":"OHP","DrugName":"IBUPROFEN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96295014187"},{"Id":421004,"FormularyType":"OHP","DrugName":"PSEUDOEPHEDR TAB 120MG ER","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"96295014196"},{"Id":421005,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"96295014198"},{"Id":421006,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"96295014199"},{"Id":421007,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"96295014200"},{"Id":421008,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"96295014201"},{"Id":421009,"FormularyType":"OHP","DrugName":"ASPIRIN REGI TAB 81MG","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"96295014202"},{"Id":421010,"FormularyType":"OHP","DrugName":"GLUCOSE CHW GUMMIES","DosageForm":"CHEW - Tablet Chewable","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"ANTIDIABETICS","DrugSubClass":"DIABETIC OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"27300030000509","GenericName":"GLUCOSE CHEW TAB 2 GM (CARB EQUIV)","NDC":"96295014208"},{"Id":421011,"FormularyType":"OHP","DrugName":"FISH OIL CAP 300MG","DosageForm":"CAPS - Capsule","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"MISC. NUTRITIONAL SUBSTANCES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80500030000130","GenericName":"*OMEGA-3 FATTY ACIDS CAP 300 MG**","NDC":"96295014212"},{"Id":421012,"FormularyType":"OHP","DrugName":"MIGRAINE TAB RELIEF","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESIC COMBINATIONS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64990003200350","GenericName":"ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG","NDC":"96295014215"},{"Id":421013,"FormularyType":"OHP","DrugName":"SLEEP-AID CAP 50MG","DosageForm":"CAPS - Capsule","Strength":"50","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300020100110","GenericName":"DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG","NDC":"96295014230"},{"Id":421014,"FormularyType":"OHP","DrugName":"8 HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"96295014252"},{"Id":421015,"FormularyType":"OHP","DrugName":"8HR PAIN REL TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"96295014253"},{"Id":421016,"FormularyType":"OHP","DrugName":"8 HR PAIN TAB 650MG","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"96295014254"},{"Id":421017,"FormularyType":"OHP","DrugName":"LICE KILLING SHA 0.33-4%","DosageForm":"SHAM - Shampoo","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"SCABICIDES & PEDICULICIDES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90909902104540","GenericName":"PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4%","NDC":"96295014261"},{"Id":421018,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"96295014299"},{"Id":421019,"FormularyType":"OHP","DrugName":"PEN NEEDLES MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"96295014300"},{"Id":421020,"FormularyType":"OHP","DrugName":"12HR DECONGE TAB 120MG CR","DosageForm":"TB12 - Tablet ER 12HR","Strength":"120","BrandVsGeneric":"Y","DrugCategory":"NASAL AGENTS - SYSTEMIC AND TOPICAL","DrugSubClass":"SYMPATHOMIMETIC DECONGESTANTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"42101020107405","GenericName":"PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG","NDC":"96295014304"},{"Id":421021,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL LEMON","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"96295014309"},{"Id":421022,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL CHERRY","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"96295014310"},{"Id":421023,"FormularyType":"OHP","DrugName":"MAG CITRATE SOL GRAPE","DosageForm":"SOLN - Solution","Strength":"1.745","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SALINE LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46100020102000","GenericName":"MAGNESIUM CITRATE SOLN","NDC":"96295014311"},{"Id":421024,"FormularyType":"OHP","DrugName":"ADAPALENE GEL 0.1%","DosageForm":"GEL - Gel","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ACNE PRODUCTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90050003004010","GenericName":"ADAPALENE GEL 0.1%","NDC":"96295014313"},{"Id":421025,"FormularyType":"OHP","DrugName":"VITAMIN B-1 TAB 100MG","DosageForm":"TABS - Tablet","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"WATER SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77101010100330","GenericName":"THIAMINE HCL TAB 100 MG","NDC":"96295014328"},{"Id":421026,"FormularyType":"OHP","DrugName":"HYDROCORT CRE 1% ALOE","DosageForm":"CREA - Cream","Strength":"1","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"CORTICOSTEROIDS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90550075003720","GenericName":"HYDROCORTISONE CREAM 1%","NDC":"96295014329"},{"Id":421027,"FormularyType":"OHP","DrugName":"PAIN & FEVER SUS 160/5ML","DosageForm":"SUSP - Suspension","Strength":"160","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010001840","GenericName":"ACETAMINOPHEN SUSP 160 MG/5ML","NDC":"96295014339"},{"Id":421028,"FormularyType":"OHP","DrugName":"ANTIFUNGAL POW 2%","DosageForm":"POWD - Powder","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"DERMATOLOGICALS","DrugSubClass":"ANTIFUNGALS - TOPICAL","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"90154050102910","GenericName":"MICONAZOLE NITRATE POWDER 2%","NDC":"96295014350"},{"Id":421029,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295014355"},{"Id":421030,"FormularyType":"OHP","DrugName":"ANTACID CHW 750MG","DosageForm":"CHEW - Tablet Chewable","Strength":"750","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000520","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG","NDC":"96295014356"},{"Id":421031,"FormularyType":"OHP","DrugName":"ANTACID CHW 1000MG","DosageForm":"CHEW - Tablet Chewable","Strength":"1000","BrandVsGeneric":"Y","DrugCategory":"ANTACIDS","DrugSubClass":"ANTACIDS - CALCIUM SALTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"48300010000545","GenericName":"CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG","NDC":"96295014357"},{"Id":421032,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"96295014372"},{"Id":421033,"FormularyType":"OHP","DrugName":"ALLERGY CHLD LIQ 12.5/5ML","DosageForm":"LIQD - Liquid","Strength":"12.5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100920","GenericName":"DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML","NDC":"96295014420"},{"Id":421034,"FormularyType":"OHP","DrugName":"CLEARLAX POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"96295014421"},{"Id":421035,"FormularyType":"OHP","DrugName":"OLOPATADINE SOL 0.2%","DosageForm":"SOLN - Solution","Strength":"0.2","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102030","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","NDC":"96295014469"},{"Id":421036,"FormularyType":"OHP","DrugName":"OLOPATADINE DRO 0.1%","DosageForm":"SOLN - Solution","Strength":"0.1","BrandVsGeneric":"Y","DrugCategory":"OPHTHALMIC AGENTS","DrugSubClass":"OPHTHALMICS - MISC.","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"86802065102020","GenericName":"OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","NDC":"96295014470"},{"Id":421037,"FormularyType":"OHP","DrugName":"IBUPROFEN PM TAB 200-38MG","DosageForm":"TABS - Tablet","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60309902400320","GenericName":"IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG","NDC":"96295014475"},{"Id":421038,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295014491"},{"Id":421039,"FormularyType":"OHP","DrugName":"24HR ALLERGY TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96295014493"},{"Id":421040,"FormularyType":"OHP","DrugName":"8HR ARTHRITS TAB 650MG ER","DosageForm":"TBCR - Tablet ER","Strength":"650","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000420","GenericName":"ACETAMINOPHEN TAB ER 650 MG","NDC":"96295014517"},{"Id":421041,"FormularyType":"OHP","DrugName":"LAXACLEAR POW","DosageForm":"POWD - Powder","Strength":"17","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"LAXATIVES - MISCELLANEOUS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46600033002910","GenericName":"POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP","NDC":"96619011299"},{"Id":421042,"FormularyType":"OHP","DrugName":"KLS ASPIRIN TAB 81MG EC","DosageForm":"TBEC - Tablet DR","Strength":"81","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"SALICYLATES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64100010000601","GenericName":"ASPIRIN TAB DELAYED RELEASE 81 MG","NDC":"96619031071"},{"Id":421043,"FormularyType":"OHP","DrugName":"ALLER-TEC TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020100320","GenericName":"CETIRIZINE HCL TAB 10 MG","NDC":"96619031167"},{"Id":421044,"FormularyType":"OHP","DrugName":"KLS IBUPROFN TAB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96619035540"},{"Id":421045,"FormularyType":"OHP","DrugName":"ACETAMIN TAB 500MG","DosageForm":"TABS - Tablet","Strength":"500","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - NONNARCOTIC","DrugSubClass":"ANALGESICS OTHER","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"64200010000315","GenericName":"ACETAMINOPHEN TAB 500 MG","NDC":"96619038324"},{"Id":421046,"FormularyType":"OHP","DrugName":"KLS QUIT4 GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"96619038866"},{"Id":421047,"FormularyType":"OHP","DrugName":"KLS QUIT2 GUM 2MG","DosageForm":"GUM - Gum","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002810","GenericName":"NICOTINE POLACRILEX GUM 2 MG","NDC":"96619038867"},{"Id":421048,"FormularyType":"OHP","DrugName":"ESOMEPRA MAG CAP 20MG DR","DosageForm":"CPDR - Capsule Delayed Release","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"PROTON PUMP INHIBITORS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49270025106520","GenericName":"ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","NDC":"96619038870"},{"Id":421049,"FormularyType":"OHP","DrugName":"KLS D3 CAP 50MCG","DosageForm":"CAPS - Capsule","Strength":"2000","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000120","GenericName":"CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)","NDC":"96619039391"},{"Id":421050,"FormularyType":"OHP","DrugName":"ACID CONTROL TAB 20MG","DosageForm":"TABS - Tablet","Strength":"20","BrandVsGeneric":"Y","DrugCategory":"ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS","DrugSubClass":"H-2 ANTAGONISTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"49200030000320","GenericName":"FAMOTIDINE TAB 20 MG","NDC":"96619043921"},{"Id":421051,"FormularyType":"OHP","DrugName":"ALLERCLEAR TAB 10MG","DosageForm":"TABS - Tablet","Strength":"10","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550030000320","GenericName":"LORATADINE TAB 10 MG","NDC":"96619052968"},{"Id":421052,"FormularyType":"OHP","DrugName":"ALLER-TEC SOL 1MG/ML","DosageForm":"SOLN - Solution","Strength":"5","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550020102010","GenericName":"CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML)","NDC":"96619053540"},{"Id":421053,"FormularyType":"OHP","DrugName":"KLS ALLERGY TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"96619053609"},{"Id":421054,"FormularyType":"OHP","DrugName":"STOOL SOFTEN CAP 100MG","DosageForm":"CAPS - Capsule","Strength":"100","BrandVsGeneric":"Y","DrugCategory":"LAXATIVES","DrugSubClass":"SURFACTANT LAXATIVES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"46500010300110","GenericName":"DOCUSATE SODIUM CAP 100 MG","NDC":"96619062924"},{"Id":421055,"FormularyType":"OHP","DrugName":"KLS QUIT4 LOZ 4MG","DosageForm":"LOZG - Lozenge","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004720","GenericName":"NICOTINE POLACRILEX LOZENGE 4 MG","NDC":"96619063250"},{"Id":421056,"FormularyType":"OHP","DrugName":"KLS QUIT2 LOZ 2MG","DosageForm":"LOZG - Lozenge","Strength":"2","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010004710","GenericName":"NICOTINE POLACRILEX LOZENGE 2 MG","NDC":"96619063251"},{"Id":421057,"FormularyType":"OHP","DrugName":"SLEEP AID TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS","DrugSubClass":"ANTIHISTAMINE HYPNOTICS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"60300010100310","GenericName":"DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","NDC":"96619085769"},{"Id":421058,"FormularyType":"OHP","DrugName":"KLS IBUPROFN TAB IB 200MG","DosageForm":"TABS - Tablet","Strength":"200","BrandVsGeneric":"Y","DrugCategory":"ANALGESICS - ANTI-INFLAMMATORY","DrugSubClass":"NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"66100020000305","GenericName":"IBUPROFEN TAB 200 MG","NDC":"96619088088"},{"Id":421059,"FormularyType":"OHP","DrugName":"KLS QUIT4 GUM 4MG","DosageForm":"GUM - Gum","Strength":"4","BrandVsGeneric":"Y","DrugCategory":"PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.","DrugSubClass":"SMOKING DETERRENTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"62100010002820","GenericName":"NICOTINE POLACRILEX GUM 4 MG","NDC":"96619092166"},{"Id":421060,"FormularyType":"OHP","DrugName":"ALLER-FEX TAB 180MG","DosageForm":"TABS - Tablet","Strength":"180","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - NON-SEDATING","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41550024100350","GenericName":"FEXOFENADINE HCL TAB 180 MG","NDC":"96619098776"},{"Id":421061,"FormularyType":"OHP","DrugName":"ALLERGY RELF TAB 25MG","DosageForm":"TABS - Tablet","Strength":"25","BrandVsGeneric":"Y","DrugCategory":"ANTIHISTAMINES","DrugSubClass":"ANTIHISTAMINES - ETHANOLAMINES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"41200030100305","GenericName":"DIPHENHYDRAMINE HCL TAB 25 MG","NDC":"97644032936"},{"Id":421062,"FormularyType":"OHP","DrugName":"MAXPRO-18G LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"Y","DrugCategory":"NUTRIENTS","DrugSubClass":"PROTEINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"80301010000900","GenericName":"*PROTEIN ORAL LIQUID***","NDC":"98254000237"},{"Id":421063,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"98302000105"},{"Id":421064,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"98302000198"},{"Id":421065,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"98302000199"},{"Id":421066,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"98302000200"},{"Id":421067,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146358","GenericName":"INSULIN PEN NEEDLE 31 G X 5 MM (1/5\" OR 3/16\")","NDC":"98302001430"},{"Id":421068,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146361","GenericName":"INSULIN PEN NEEDLE 31 G X 6 MM (1/4\" OR 15/64\")","NDC":"98302001431"},{"Id":421069,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 31GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146364","GenericName":"INSULIN PEN NEEDLE 31 G X 8 MM (1/3\" OR 5/16\")","NDC":"98302001432"},{"Id":421070,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"98302001433"},{"Id":421071,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"98302001434"},{"Id":421072,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"98302001435"},{"Id":421073,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906387","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16\"","NDC":"98302013919"},{"Id":421074,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906388","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16\"","NDC":"98302013920"},{"Id":421075,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906318","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16\"","NDC":"98302013930"},{"Id":421076,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906307","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16\"","NDC":"98302013931"},{"Id":421077,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906328","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16\"","NDC":"98302013932"},{"Id":421078,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906384","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16\"","NDC":"98302013933"},{"Id":421079,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906308","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2\"","NDC":"98302013934"},{"Id":421080,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906329","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2\"","NDC":"98302013935"},{"Id":421081,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/30G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906386","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2\"","NDC":"98302013936"},{"Id":421082,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906327","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2\"","NDC":"98302013937"},{"Id":421083,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906380","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2\"","NDC":"98302013938"},{"Id":421084,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906320","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2\"","NDC":"98302013939"},{"Id":421085,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/28G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906370","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2\"","NDC":"98302013940"},{"Id":421086,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/29G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906305","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2\"","NDC":"98302013941"},{"Id":421087,"FormularyType":"OHP","DrugName":"D-VITAMIN DRO 400UNIT","DosageForm":"LIQD - Liquid","Strength":"400","BrandVsGeneric":"Y","DrugCategory":"VITAMINS","DrugSubClass":"OIL SOLUBLE VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"77202032000915","GenericName":"CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML)","NDC":"98302014002"},{"Id":421088,"FormularyType":"OHP","DrugName":"PED TRI-VIT DRO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC VITAMINS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78401503002006","GenericName":"*PEDIATRIC VITAMINS ADC DROPS 750 UNIT-400 UNIT-35 MG/ML***","NDC":"98302014003"},{"Id":421089,"FormularyType":"OHP","DrugName":"PED POLY-VIT DRO","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PEDIATRIC MULTIPLE VITAMINS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78410000002000","GenericName":"*PEDIATRIC MULTIPLE VITAMIN DROPS**","NDC":"98302014004"},{"Id":421090,"FormularyType":"OHP","DrugName":"PED POLY-VIT DRO /IRON","DosageForm":"SOLN - Solution","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MULTIVITAMINS","DrugSubClass":"PED MV W/ IRON","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":true,"AgeMin":"","AgeMinUnit":"","AgeMax":"12","AgeMaxUnit":"Y","GenericProductIdentifier":"78430000002010","GenericName":"*PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**","NDC":"98302014005"},{"Id":421091,"FormularyType":"OHP","DrugName":"PEDIATRIC DRO IRON","DosageForm":"SOLN - Solution","Strength":"15","BrandVsGeneric":"Y","DrugCategory":"HEMATOPOIETIC AGENTS","DrugSubClass":"IRON","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"82300010002003","GenericName":"FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)","NDC":"98302014006"},{"Id":421092,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/27G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906350","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2\"","NDC":"98302014043"},{"Id":421093,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.3/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906333","GenericName":"INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64\"","NDC":"98302014044"},{"Id":421094,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 0.5/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906391","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64\"","NDC":"98302014045"},{"Id":421095,"FormularyType":"OHP","DrugName":"INSULIN SYRG MIS 1ML/31G","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051030906399","GenericName":"INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","NDC":"98302014046"},{"Id":421096,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146366","GenericName":"INSULIN PEN NEEDLE 32 G X 4 MM (1/6\" OR 5/32\")","NDC":"98302014059"},{"Id":421097,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"98302014172"},{"Id":421098,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146367","GenericName":"INSULIN PEN NEEDLE 32 G X 5 MM (1/5\" OR 3/16\")","NDC":"98302014173"},{"Id":421099,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146368","GenericName":"INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","NDC":"98302014174"},{"Id":421100,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 32GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146372","GenericName":"INSULIN PEN NEEDLE 32 G X 8 MM (1/3\" OR 5/16\")","NDC":"98302014175"},{"Id":421101,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"98302014176"},{"Id":421102,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 33GX5MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146377","GenericName":"INSULIN PEN NEEDLE 33 G X 5 MM (1/5\" OR 3/16\")","NDC":"98302014177"},{"Id":421103,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 33GX6MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146378","GenericName":"INSULIN PEN NEEDLE 33 G X 6 MM (1/4\" OR 15/64\")","NDC":"98302014178"},{"Id":421104,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 33GX8MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146380","GenericName":"INSULIN PEN NEEDLE 33 G X 8 MM (1/3\" OR 5/16\")","NDC":"98302014179"},{"Id":421105,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 33GX4MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146376","GenericName":"INSULIN PEN NEEDLE 33 G X 4 MM (1/6\" OR 5/32\")","NDC":"98302014807"},{"Id":421106,"FormularyType":"OHP","DrugName":"COMFORT EZ MIS 29GX12MM","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"PARENTERAL THERAPY SUPPLIES","PriorAuthRequired":false,"StepTherapy":true,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97051050146330","GenericName":"INSULIN PEN NEEDLE 29 G X 12 MM (1/2\")","NDC":"98302014808"},{"Id":421107,"FormularyType":"OHP","DrugName":"ALCOHOL PREP PAD 70%","DosageForm":"PADS - Pad","Strength":"70","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"MISC. DEVICES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97703040004300","GenericName":"*ALCOHOL SWABS***","NDC":"98302015226"},{"Id":421108,"FormularyType":"OHP","DrugName":"NUTREN 1.0 LIQ /FIB UNF","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006056"},{"Id":421109,"FormularyType":"OHP","DrugName":"NUTREN JR LIQ 1.0","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006062"},{"Id":421110,"FormularyType":"OHP","DrugName":"NUTREN LIQ JR/FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006063"},{"Id":421111,"FormularyType":"OHP","DrugName":"RENALCAL LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006064"},{"Id":421112,"FormularyType":"OHP","DrugName":"NUTREN 1.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006210"},{"Id":421113,"FormularyType":"OHP","DrugName":"NUTREN 2.0 LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006230"},{"Id":421114,"FormularyType":"OHP","DrugName":"REPLETE FIBE LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006245"},{"Id":421115,"FormularyType":"OHP","DrugName":"REPLETE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006249"},{"Id":421116,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006252"},{"Id":421117,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006253"},{"Id":421118,"FormularyType":"OHP","DrugName":"PEPTAMEN LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006269"},{"Id":421119,"FormularyType":"OHP","DrugName":"GLYTROL LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006275"},{"Id":421120,"FormularyType":"OHP","DrugName":"NUTRIHEP 1.5 LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006479"},{"Id":421121,"FormularyType":"OHP","DrugName":"NUTREN LIQ PULMONAR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716006480"},{"Id":421122,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716007363"},{"Id":421123,"FormularyType":"OHP","DrugName":"PEPTAMEN LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716008190"},{"Id":421124,"FormularyType":"OHP","DrugName":"PEPTAMEN LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716008192"},{"Id":421125,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716008543"},{"Id":421126,"FormularyType":"OHP","DrugName":"PEPTAMEN 1 LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716012804"},{"Id":421127,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016261"},{"Id":421128,"FormularyType":"OHP","DrugName":"NUTREN 1.5 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016354"},{"Id":421129,"FormularyType":"OHP","DrugName":"REPLETE LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016356"},{"Id":421130,"FormularyType":"OHP","DrugName":"REPLETE LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016358"},{"Id":421131,"FormularyType":"OHP","DrugName":"REPLETE LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016359"},{"Id":421132,"FormularyType":"OHP","DrugName":"NUTREN LIQ PULMONAR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016362"},{"Id":421133,"FormularyType":"OHP","DrugName":"GLYTROL LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016376"},{"Id":421134,"FormularyType":"OHP","DrugName":"GLYTROL LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716016377"},{"Id":421135,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716017363"},{"Id":421136,"FormularyType":"OHP","DrugName":"PEPTAMEN/ LIQ PREBIO1","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716018185"},{"Id":421137,"FormularyType":"OHP","DrugName":"PEPTAMEN LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716018194"},{"Id":421138,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1.5 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716018543"},{"Id":421139,"FormularyType":"OHP","DrugName":"NUTREN 2.0 LIQ CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716033147"},{"Id":421140,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716036415"},{"Id":421141,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716036416"},{"Id":421142,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716060140"},{"Id":421143,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ VANILLA","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716060200"},{"Id":421144,"FormularyType":"OHP","DrugName":"PEPTAMEN AF LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716066360"},{"Id":421145,"FormularyType":"OHP","DrugName":"PEPTAMEN AF LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716066370"},{"Id":421146,"FormularyType":"OHP","DrugName":"PEPTAMEN AF LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716066380"},{"Id":421147,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1 CAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716067350"},{"Id":421148,"FormularyType":"OHP","DrugName":"NUTREN JR LIQ","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716067370"},{"Id":421149,"FormularyType":"OHP","DrugName":"NUTREN JR LIQ FIBER","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716067390"},{"Id":421150,"FormularyType":"OHP","DrugName":"PEPTAMEN JR LIQ 1.5 KCAL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716070482"},{"Id":421151,"FormularyType":"OHP","DrugName":"PEPTAMEN AF LIQ UNFLAVOR","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"98716076390"},{"Id":421152,"FormularyType":"OHP","DrugName":"FREESTYLE TES","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"99073012050"},{"Id":421153,"FormularyType":"OHP","DrugName":"FREESTYLE TES","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"99073012101"},{"Id":421154,"FormularyType":"OHP","DrugName":"FREESTYLE MIS LANCETS","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"99073013001"},{"Id":421155,"FormularyType":"OHP","DrugName":"FREESTYLE LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"99073014002"},{"Id":421156,"FormularyType":"OHP","DrugName":"FREESTYLE MIS UNISTICK","DosageForm":"MISC - Miscellaneous","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202025006300","GenericName":"*LANCETS***","NDC":"99073070428"},{"Id":421157,"FormularyType":"OHP","DrugName":"FREESTYLE LIQ CONTROL","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202007100900","GenericName":"*BLOOD GLUCOSE CALIBRATION - LIQUID***","NDC":"99073070432"},{"Id":421158,"FormularyType":"OHP","DrugName":"FREESTYLE KIT LITE","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202010006410","GenericName":"*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","NDC":"99073070805"},{"Id":421159,"FormularyType":"OHP","DrugName":"FREESTYLE TES LITE","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"99073070822"},{"Id":421160,"FormularyType":"OHP","DrugName":"FREESTYLE TES LITE","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"99073070827"},{"Id":421161,"FormularyType":"OHP","DrugName":"FREESTYLE KIT FREE LIT","DosageForm":"KIT - Kit","Strength":"0","BrandVsGeneric":"N","DrugCategory":"MEDICAL DEVICES AND SUPPLIES","DrugSubClass":"DIABETIC SUPPLIES","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":false,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"97202010006410","GenericName":"*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","NDC":"99073070914"},{"Id":421162,"FormularyType":"OHP","DrugName":"FREESTYLE TES INSULINX","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"99073071227"},{"Id":421163,"FormularyType":"OHP","DrugName":"FREESTYLE TES INSULINX","DosageForm":"STRP - Strip","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIAGNOSTIC PRODUCTS","DrugSubClass":"DIAGNOSTIC TESTS","PriorAuthRequired":false,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"94100030006100","GenericName":"GLUCOSE BLOOD TEST STRIP","NDC":"99073071230"},{"Id":421164,"FormularyType":"OHP","DrugName":"ENTERADE LIQ ORANGE","DosageForm":"LIQD - Liquid","Strength":"0","BrandVsGeneric":"N","DrugCategory":"DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS","DrugSubClass":"NUTRITIONAL SUPPLEMENTS","PriorAuthRequired":true,"StepTherapy":false,"QuantityLimit":true,"DrugTier":"","PriorAuthType":"","StepTherapyType":"","StepTherapyDetails":"","MailOrder":false,"AgeLimit":false,"AgeMin":"","AgeMinUnit":"","AgeMax":"","AgeMaxUnit":"","GenericProductIdentifier":"81200000000900","GenericName":"*NUTRITIONAL SUPPLEMENT LIQUID**","NDC":"99422099248"}]